NEW YORK CITY DEPARTMENT OF FINANCE   COLLECTIONSl                DIVISION                  FOR OFFICE USE ONLY 
                                                                                                            DATE RECEIVED: ___________ 
                              APPLICATION FOR   
                                                                                                            TSA NUMBER: _____________ 
                              TAX  STATUS REPORT                                                            AUDITOR: _______________
         Mail to: NYC Dept. of Finance, Collections Division, Tax Status, 59 Maiden Lane, 24th Floor, New York, NY  10038
 Instructions:  Please complete and sign this application before mailing to the address above. See below for further details.

 SECTION I - APPLICANT’S INFORMATION
  
 Applicant's                                                                        Taxpayer’s 
 Name:_________________________________________________________ Email Address: ______________________________ 
                  PRINT FIRST NAME                          PRINT LAST NAME 
  Applicant's 
 Address: __________________________________________________________________________________________________ 
                                          NUMBER AND STREET                                     APT/STE       
                                                                             
 City                                     Zip                               Country             Telephone 
 and State:_____________________________ Code: ___________ (if not US): __________ Number: _______________________ 
   
 Name of                                                                            Employer 
 Subject Corporation: _______________________________________________ Identification Number _______________________  
  
 Subject 
 Corporation's Address: _______________________________________________________________________________________ 
                                          NUMBER AND STREET                                     APT/STE       
                                                                             
 City                                     Zip                               Country             Telephone 
 and State:_____________________________ Code: ___________ (if not US): __________ Number: _______________________ 
  
  State or County                         Date of                                               Date Business 
 of Incorporation: ________________________ Incorporation: _______/_______/______ Began (in NYC): _______/_______/_______

 SECTION II - CERTIFICATION
 I certify that the statements made herein have been examined by me and are, to the best of my knowledge and belief, true, correct and complete. 
 
Please sign and date: 
 
__________________________________________________________________________  DATE ____________ ____________/ ____________/
                         Signature 

RELATIONSHIP TO                   q  REPRESENTATIVE                    q  OFFICER 
CORPORATION (Check one):                 (see instructions) 

 INSTRUCTIONS FOR TAX STATUS REPORT
 All Sections of this application must be completed in its entirety.

 Power of Attorney: 
 Submit a fully-executed Power of Attorney form with the application.  This must be submitted by any authorized rep-
 resentative of the subject corporation requesting the tax status report.  Incomplete applications will not be accepted. 
  
 Mailing Address: 
 Mail this completed application and completed Power of Attorney form (if applicable) to:                                 
                                          NYC Department of Finance 
                                          Collections Division, Tax Status 
                                          59 Maiden Lane, 24th Floor 
                                          New York, NY  10038 
       
 If you have any questions, call Tax Status at (929) 512-8149 or (929) 512-8148.

                                                                                                                           Tax Status  Application 2022