Form 6750 Fillable Application for Voluntary Disclosure
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

A description of the qualified business entity s business activities A description of the qualified business entity s business in Alaska A statement with your estimate of the amount of taxes due by tax period Show the accompanying computations If the entity is a partnership or LLC the number of corporate partners or members The facts giving rise to the offer to enter into a Voluntary Disclosure Agreement The settlement terms proposed by the company Whether the DOR has contacted the entity and if so the nature of such contacts 0405 6750 Rev 01/01/14 550 W 7th Ave Ste 500 6750:01/01/14 907 269 6620 907 269 6644 a settlement under Alaska s Voluntary Disclosure Program and that the information in this application including accompanying schedules and Alaska Application For Voluntary Disclosure Anchorage AK 99501 3555 Attach the following information to the application: City State Zip Code Corporation Department of Revenue Tax Division Department of Revenue? dor tax disclosure@alaska gov Entity Type: Fax Number Form 6750 Has the entity ever been the subject of an inquiry by Has the entity ever filed an income tax return with the 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 income taxes? LLC (Limited Liability Company) Mailing Address Part I Part II Part III Part IV Partnership Person Completing Form (Print Name) Questions? Email Representative s Email Address Representative s Fax Representative s Mailing Address Representative s Name Representative s Telephone Number S Corporation Signature State Agency statements is true and correct to the best of my knowledge and belief Tax Periods: Telephone Number the Department of Revenue with respect to liability for