Attachment E certgoodstandingform~1.pdf

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

Massachusetts

Department of

Revenue

This application may be used to request a Certificate of Good Standing/Letter of Compliance, Waiver of Corporate 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 as soon as 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 (required)

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 proprietor Individual LLP 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 (required) Under the penalties of perjury, I declare that my company is not responsible for the following taxes (check all that apply):

Withholding Sales/Use Meals Room Occupancy

Signature of taxpayer or corporate officer (required)

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 not authorized 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 Signature Date

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, must be submitted.

If the applicant is a partnership, a copy of each of the last two years of Form 3, Partnership Return of Income, must be 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 must be 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.

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