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Massachusetts Department of Revenue
Form 121A
Urban Redevelopment Excise Return 2020
Massachusetts General Laws, Chapter 121A, section 10, as amended for the calendar year 2020.
Name of taxpayer Federal Identification number
Street address
City/Town State Zip Phone number
Present location of principle office in Massachusetts
Name of project DOR Project Identification number
Project address
City/Town State Zip Phone number
Fill in if:
Amended return (see “Amended Return” in instructions) Final return
Fill in if:
Initial return Name change Address change
1 Fill in applicable oval
Corporation Individual Trust Partnership Other (see instructions)
2 Date of charter or organization (mm/dd/yyyy) 3 Date or project approval (mm/dd/yyyy) 4 Date of project completion (mm/dd/yyyy)
5 Taxpayer’s books are in the care of Title
6 Fill in if the federal government has changed your taxable income for any prior year which has not yet been reported to Massachusetts.
If filled in, report changes by filing an amended return for each year not reported.
7 Fill in if any governmental unit has made any payments to or on behalf of any tenant of the taxable entity which are in addition to such
payments actually made by such tenant.
Enter total amount of these governmental payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Declaration
Under penalties of perjury, I declare that to the best of my knowledge and belief, this return and enclosures are true, correct and complete.
Signature of appropriate corporate officer Social Security number Phone number Date
Individual or firm signature of preparer Employer Identification number Address Date
If you are signing as an authorized delegate of the appropriate corporate officer, fill in oval and enclose Massachusetts Form M-2848,
Power of Attorney.
The undersigned is the authorized representative to whom contents may be disclosed in discussing questions which may arise in connec-
tion with this return.
Name of person authorized Signature of person authorized Phone number
Address City/Town State Zip
Mail return, with payment in full, to Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or money order payable
to Commonwealth of Massachusetts.
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