MAINE REVENUE SERVICES TAX CLEARANCE
MAINE GAMBLING CONTROL BOARD
|Applicant Name: |Phone #: |
|(Please Print Clearly) | |
|Social Security #: |Date of Birth: |
|Taxpayer Current Address: |Alternate name you may have filed under: |
1. Do you have any State of Maine tax liability that is currently outstanding? ( No ( Yes
If YES, please explain:_________________________________________________________________
___________________________________________________________________________________
2. Are you required to file any Maine State return(s) other than individual income tax ( No ( Yes
If YES, please list tax type and account #:__________________________________________________
___________________________________________________________________________________
3. Have you filed a Maine State Income Tax Return every year for the past 7 years?
( No ( Yes If NO, please list the year(s) and explain why the return(s) was not filed:
________________________________________________________________________________________________________________________________________________________________________
4. Are there any Maine State tax returns that have not been filed because you lived outside the State of Maine? ( No ( Yes If YES, what years, what state(s), and what date did you return
to Maine:____________________________________________________________________________
____________________________________________________________________________________
NOTE: Any question that has not been answered completely and correctly will delay the tax clearance process. Please be specific.
I authorize the Maine Gambling Control Board, their designees and the Maine State Police to share my social security number and tax history with Maine Revenue Services for tax background purposes. I also authorize Maine Revenue Services to release my tax history results back to the Maine Gambling Control Board, their Designees and the Maine State Police.
Applicant Signature:___________________________________Date:___________________________
MRS – Office Use Only
Clearance Granted: ( Yes ( No If No, reason:___________________________________
____________________________________________________________________________________
MRS Clearance Officer:________________________________ Date:____________________________
Tracer Needed: ( Yes ( No F107 Notes: (
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