Form 355-7004 Misc - Application For Extension Of Time To File Financial Institution, Insurance Or Miscellaneous - 2013

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Form 355-7004 Misc.

2013

Application for Extension of

Massachusetts

Time to File Financial Institution,

Department of

Insurance or Miscellaneous

Revenue

This application may be filed by corporations filing Form 63FI, 63-20P, 63-23P, 121A, P.S.1 or 63-29A. All other business/manufacturing corpora-

tions that file Forms 355, 355S, 355U, 355SC or SBC Corporation Excise Returns must file Form 355-7004 when applying for an extension of

time to file.

pplication for Extension

Name of corporation

Federal Identification number

For tax year beginning

Ending

Street address

City/Town

State

Zip

Return to be filed:

Financial institutions

Insurance

Public utility

Urban redevelopment

Ocean marine

Type of extension being applied for:

a. Automatic six-month extension

b. Extension until:

Reason for extension:

Tentative Return

1 Estimated amount of tax for the taxable year (must be at least minimum tax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Advance and/or estimated payments made (if any). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Tax due with this application. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Payment in full of the tax due must be made with this application for it to be considered valid. If at least 50% of the tax due or the minimum tax (whichever

is greater) for the taxable year is not paid, the extension is null and void. Penalties for a late return will be assessed from the original due date of the return.

Declaration

I declare under the penalties of perjury that I have been authorized by the above-named corporation to make this application and that to the

best of my knowledge and belief the statements made herein are true and correct.

Signature of officer or agent

Title

Date

Signature of paid preparer

Address

Date

Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204.