NEW YORK CITY DEPARTMENT OF FINANCE  COLLECTIONSl        DIVISION                      FOR OFFICE USE ONLY
            TM
                                                                                                          DATE RECEIVED: ___________
                               APPLICATION FOR 
Department of Finance                                                                                     TSA NUMBER: _____________
                               TAX STATUS REPORT
                                                                                                          AUDITOR: _______________
       Mail to: NYC Dept. of Finance, Collections Division, Tax Status, 59 Maiden Lane, 24th Floor, New York, NY  10038
Instructions: Please complete and sign this application before mailing to the address above. See below for further details.

SECTION I - APPLICANT’S INFORMATION

Applicant's                                                                        Taxpayer’s
Name:_________________________________________________________PRINT FIRST NAME PRINT LAST NAMEEmail Address:______________________________
Applicant's
Address:__________________________________________________________________________________________________NUMBER AND STREET APT/STE
City                                 Zip                                   Country                    Telephone
and State:_____________________________ Code:___________ (if not US):__________ Number:_______________________

Name of                                                                                       Employer
Subject Corporation:_______________________________________________ Identification Number_______________________

Subject
Corporation's Address:_______________________________________________________________________________________NUMBER AND STREET APT/STE
City                                 Zip                                   Country                    Telephone
and State:_____________________________ Code:___________ (if not US):__________ Number:_______________________

State or County                      Date of                                                        Date Business
of Incorporation:________________________ Incorporation: _______/_______/______ Began (in NYC): _______/_______/_______

SECTION II - CERTIFICATION
I certify that the statements made herein have been examined by me and are, to the best of my knowledge and belief, true, correct and complete.
Please sign and date:

__________________________________________________________________________ DATE____________ ____________/ ____________/
                          Signature
RELATIONSHIP TO                q    REPRESENTATIVE               q OFFICER
CORPORATION (Check one):            (see instructions)

INSTRUCTIONS FOR TAX STATUS REPORT

All Sections of this application must be completed in its entirety.

Power of Attorney:
Submit a fully-executed Power of Attorney form with the application.  This must be submitted by any authorized rep-
resentative of the subject corporation requesting the tax status report.  Incomplete applications will not be accepted.
Mailing Address:
Mail this completed application and completed Power of Attorney form (if applicable) to:
                                     NYC Department of Finance
                                     Collections Division, Tax Status
                                     59 Maiden Lane, 24th Floor
                                     New York, NY  10038

If you have any questions, call Tax Status at (212) 908-7623 or (212) 908-7010.

                                                                                                                        Tax Status  Application 2017