Request for a Certificate of                                               Massachusetts
                                        Good Standing and/or Tax Compliance                                               Department of
                                                                                                                          Revenue
                                          or Waiver of Corporate Tax Lien

This application may be used to request a Certificate of Good Standing/Letter of Compliance, Waiver ofCorporate Tax Lien, or Certificate of
Good Standing for a Non-Profit Organization.
If this matter is to be discussed with any third parties, complete the Power of Attorney section below. Mail your request asonsoas possible to
Massachusetts Department of Revenue, PO Box 7066, Boston, MA 02204 or fax to (617) 887-6262. For further information, call (617) 887-6550.
Name of organization                                                   Trade name or DBA                Federal ID or Social Security number

Street address                                                         City/Town                        State       Zip

Contact person                                                                                          Daytime telephone

Street address (if different from above)                               City/Town                        State       Zip

Type of Application
Type of organization(check one):
   Corporation       Partnership          Sole proprietorIndividualLLP       LLC Other
Purpose of application  (check one):
   Certificate of Good Standing/Letter of Compliance      Certificate of Good Standing for a Non-Profit Organization
   Waiver of Corporate Tax Lien
If requesting Waiver of Corporate Tax Lien, attach price and legal description of assets to be sold and complete the following:
Name of transferee                                                                                      Date of transfer or sale

Street address                                                         City/Town                        State       Zip

Affidavit
Under the penalties of perjury, I declare that my company is not responsible for the following taxes(check all that apply):
   Withholding       Sales/Use            MealsRoom Occupancy
Signature of taxpayer or corporate officer

Power of Attorney
Complete this section if you wish to authorize another individual to sign documents on your behalf. In addition, that individual (“attorney-in-fact”)
must complete the Declaration of Representative section on reverse.
Name of attorney-in-fact                                                                                Daytime telephone

Street address                                                         City/Town                        State       Zip

I,                                                       , hereby authorize the above-named individual to represent me as attorney-in-fact before
the Certificate Unit of the Massachusetts Department of Revenue for the following type(s) of tax, and for the period(s) of time indicated.
                        Type of tax                                    Period                                Type of tax                             Period

Power of Attorney          (cont’d.)
The above-named attorney-in-fact is authorized, subject to any limitations set forth below or to revocation, to receive confidential information
and to perform any and all acts that can be performed by the taxpayer with respect to the above-specified tax type(s), excluding the power to
receive tax refund checks. The attorney-in-fact is notauthorized to:
Restriction(s)

Signature of taxpayer                                                                              Date

Declaration of Representative
I declare that I am not currently under suspension or disbarment from practice within the Commonwealth or in any jurisdiction, that I am aware
of regulations governing the practice of attorneys, certified public accountants, public accountants, enrolled agents and others, and that I am one
of the following:
1. a member in good standing of the bar of the highest court of the jurisdiction shown below;
2. duly qualified to practice as a certified public accountant or public accountant in the jurisdiction shown below;
3. enrolled as an agent under the requirements of Treasury Department Circular No. 230;
4. a bona fide officer of the taxpayer organization;
5. a full-time employee of the taxpayer;
6. a member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);
7. a fiduciary for the taxpayer;
8. other (attach statement)
and that I am authorized to represent the above-named taxpayer for the above-specified tax type(s).
Designation (insert appropriate                                     Jurisdiction (state, etc.)
   number from above list)                            or enrollment card number                                                                 SignatureDate

General Information
If the applicant is a trust, a copy of each of the last two years of Form 3F, Income Tax Return of Corporate Trust, mustbe submitted.
If the applicant is a partnership, a copy of each of the last two years of Form 3, Partnership Return of Income, mustbe submitted.
If the applicant is a non-profit organization, a copy of your IRS letter of exemption under Section 501(c)(3) of the Internal Revenue Code
mustbe submitted.
Note: Any correspondence or certificate will be sent to the legal address of the taxpayer recorded at the Department of Revenue. The
corporate name printed on the certificate will be the same as the name recorded at the Secretary of State’s office.