Fillable Printable Form M-8453C 2004

Form M-8453C 2004

Form M-8453C

Corporate Tax Declaration

for Electronic Filing

2004

Massachusetts

Department of

Revenue

Please print or type. Privacy Act Notice available upon request. For the year January 1–December 31, 2004.

Corporation name Declaration control number

Mailing address Federal Identification number

City/Town State Zip Form filed: 355 355C 355S 355SC

Part 1. Tax Return Information for Electronic Filing

1 Excise due before credits (from Form 355 or 355C, line 5; Form 355S, line 8; or Form 355SC, line 7) . . . . . . . . . . . . . . . . . . 1

2 Total credits (from Form 355 or 355C, line 15; Form 355S, line 18; or Form 355SC, line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Excise due before voluntary contributions (from Form 355 or 355C, line 18; Form 355S, line 21; or Form 355SC, line 14). . . . 3

4 Overpayment amount (from Form 355 or 355C, line 24; Form 355S, line 27; or Form 355SC, line 20) . . . . . . . . . . . . . . . . . . 4

5 Tax due (from Form 355 or 355C, line 27; Form 355S, line 30; or Form 355SC, line 23) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Part 2. Tax Return Information for Extension

1 Tax payments made. Enter the total of lines 21 through line 23 from Form 355 or 355C; the total of lines 24 through 26

from Form 355S; or the total of lines 17 through line 19 from Form 355SC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Part 3. Declaration and Signature of Taxpayer

Under pains and penalties of perjury, I declare that I have reviewed the information on my return with the information I have provided to my Electronic

Return Originator and that the amounts above agree with the amounts shown on my 2004 Massachusetts return. To the best of my knowledge and belief

this information is true, correct and complete. I consent that my return, including this declaration and accompanying schedules, forms and statements be

sent to the Massachusetts Department of Revenue by my Electronic Return Originator. I authorize DOR to inform my Electronic Return Originator and/or

the transmitter when my electronic return has been accepted. In the event that it is rejected, I authorize DOR to identify the reasons for rejection so that

the return can be corrected and re-transmitted. If I have filed a balance due return, I understand that if DOR does not receive full and timely payment of

my tax liability, I will remain liable for the tax liability and all applicable penalties and interest.

Your signature Date

May the Department of Revenue discuss your return with the preparer shown below? Yes

Part 4. Declaration and Signature of Electronic Return Originator (ERO)

I declare that I have reviewed the above taxpayer’s return and that the entries on this M-8453C are complete and correct to the best of my knowledge.

(Collectors are not responsible for reviewing the taxpayer’s return; however, they must ensure that the M-8453C accurately reflects the data on the return.)

I have obtained the taxpayer’s signature before submitting this return to the Massachusetts Department of Revenue. I have provided the taxpayer with

a copy of all forms and information filed with the Massachusetts Department of Revenue. If I am also the paid preparer, under pains and penalties of

perjury I declare that I have examined the above taxpayer’s return and accompanying schedules and statements and to the best of my knowledge and

belief, they are true, correct and complete. I declare that I have verified the taxpayer’s proof of account and it agrees with the name(s) shown on this form.

This declaration of paid preparer (other than taxpayer) is based on all information of which the preparer has any knowledge.

ERO’s signature and SSN or PTIN Date EIN

Firm name (or yours, if self-employed) and address City/Town State Zip

Part 5. Declaration and Signature of Paid Preparer (if other than ERO)

Under pains and penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of

my knowledge and belief it is true, correct and complete. This declaration of paid preparer (other than taxpayer) is based on all information of which the

preparer has any knowledge.

Paid preparer’s signature and SSN or PTIN Date EIN

Firm name (or yours, if self-employed) and address City/Town State Zip

00– – –5

Check if

self-employed

Check if

self-employed

Check if also

paid preparer