Alaska Application for Voluntary Disclosure 

Form 
6750

Part I
Representative’s Name                                                  State Agency 

                                                                       Department of Revenue - Tax Division 
Representative’s Mailing Address                                       Mailing Address 

                                                                       550 W. 7th Ave. Ste. 500
City, State, ZIP Code                                                  City, State, ZIP Code

                                                                       Anchorage, AK 99501-3555
Representative’s Email Address                                         Questions? Email 

                                                                       dor.tax.disclosure@alaska.gov
Representative’s Telephone Number    Representative’s Fax              Telephone Number                    Fax Number

                                                                       907-269-6620                        907-269-6644

Part II
Tax Periods:

Entity Type:
     Corporation                                    1. Has the entity ever filed an income tax return with the Yes       No
                                                       Department of Revenue?
     S Corporation
     Partnership                                    2. Has the entity ever been the subject of an inquiry by   Yes       No
                                                       the Department of Revenue with respect to liability for 
     LLC (Limited Liability Company)                   income taxes?

Part III
Attach the following information to the application:
•  A description of the qualified business entity’s business activities
•  A description of the qualified business entity’s business in Alaska
•  The facts giving rise to the offer to enter into a Voluntary Disclosure Agreement
•  Whether the DOR has contacted the entity, and if so, the nature of such contacts
•  The settlement terms proposed by the company
•  If the entity is a partnership or LLC, the number of corporate partners or members
•  A statement with your estimate of the amount of taxes due by tax period. Show the accompanying computations.

Part IV
I declare under penalty of perjury under the laws of the State of Alaska, that I am authorized by the unnamed entity to act as its agent in negotiating 
a settlement under Alaska’s Voluntary Disclosure Program and that the information in this application, including accompanying schedules and 
statements, is true and correct to the best of my knowledge and belief.
Signature                                                              Person Completing Form (Print Name)           Date

                                                                                                               0405-6750  Rev 01/01/17