DOR_ATT_D_TAX_CHILD_SUPPORT.doc

ATTACHMENT D

Tax and Child Support Questionnaire

I authorize the Department of Revenue to conduct a tax and child support status check to verify that I have fully complied with all applicable federal, state, local tax and child support requirements. I acknowledge that in the event the Department of Revenue determines that I am in non-compliance with any applicable tax and/or child support law of the Commonwealth or other jurisdiction, I shall be subject to appropriate enforcement action to facilitate the assessment and/or collection of tax liabilities or child support obligations with the appropriate jurisdiction. I further acknowledge that non-compliance with such laws may result in my removal from services for the Department of Revenue

Printed Name of Taxpayer

Prior Name(s)

Social Security Number

Date of Birth

Street Address

City, State, Zip Code

1. Have you timely filed a federal income tax return for the tax year(s): 1999, 2000, 2001, 2002, 2003, and 2004?

Yes No. If no, list the year(s) and the reason(s) for your failure to file or to file on time:

2. If any of your federal income tax returns were filed jointly, list the name(s) and Social Security number(s) of the individual(s) with whom you filed jointly and in which year(s):

3. Have you filed a Massachusetts income tax return for the tax years (answer YES or NO for each year):

1999______ 2000______ 2001______ 2002______ 2003______ 2004_______?

If you answered NO to any of the years listed above, complete A, B, and/or C below and specify which year(s) that this statement applies to:

A. I was a legal resident of Massachusetts but my Massachusetts gross income was less than $8000 for the tax year(s) listed: _______________________________________________________________________

B. I was a non-resident of Massachusetts and I did not receive sufficient Massachusetts source income to require the filing of a Massachusetts income tax return for the tax year(s) listed: ________________________________________________________________________

C. Other:_________________________________________________________________________

(If you filed in another jurisdiction, please indicate place and year (s))

If you answered YES to any of the years in Question 1, were these returns filed timely? Yes No

If NO, list the year(s), and explain the reason(s) for your failure to timely file: ____________________________________________________________________________________________________________________________________________________________

4. If any of your Massachusetts income tax returns were filed jointly, list the name(s) and Social Security number(s) of the individual(s) with whom you filed jointly and in which year(s): ____________________________________________________________________________________________________________________________________________________________

5. Do you owe, or are you responsible for, the payment of any unpaid taxes (including local property taxes) to any local or state agency? Yes No. If YES, please explain: ____________________________________________________________________________________________________________________________________________________________

6. Do you owe or are you responsible for any unpaid child support payments in any jurisdiction? Yes No

If YES, list state(s) and explain: ____________________________________________________________________________________________________________________________________________________________

7. Are you or have you been an officer, director, partner or owner of 10% or more of any business enterprise within the last five years? Yes No. If yes, please complete a and b:

a. Business name and address

ID Number

Your Title

b. Have all the enterprises listed in 7a filed federal and Massachusetts tax returns and paid all federal and Massachusetts taxes due for the tax years: 1999, 2000, 2001, 2002, 2003, and 2004? Yes No. If no, please specify the years(s) and reason(s) for the failure to file and/or pay:

I declare under the penalties of perjury that, to the best of my knowledge and belief, the above statements are true, correct and complete. I understand that non-compliance with all applicable tax and child support laws shall constitute sufficient cause for my immediate dismissal from contract services with the Department of Revenue.

Signature______________________________________________________ Date ____________