ࡱ> AC@ bjbj>> 8(pTpT 88888LLL8,4L!j.H T  $n" % 8d..dd 884 dF88 d _`/+o  0!3,%,%_%8_\l Z\\\ 4d\\\!dddd%\\\\\\\\\ : MAINE GAMBLING CONTROL BOARD Applicant Name: (Please Print Clearly)Phone #:Social Security #:Date of Birth:Taxpayer Current Address: Alternate name you may have filed under: Do you have any State of Maine tax liability that is currently outstanding? ( No ( Yes If YES, please explain:_________________________________________________________________ ___________________________________________________________________________________ Are you required to file any Maine State return(s) other than individual income tax ( No ( Yes If YES, please list tax type and account #:__________________________________________________ ___________________________________________________________________________________ Have you filed a Maine State Income Tax Return every year for the past 7 years? ( No ( Yes If NO, please list the year(s) and explain why the return(s) was not filed: ________________________________________________________________________________________________________________________________________________________________________ Are there any Maine State tax returns that have not been filed because you lived outside the State of Maine? ( No ( Yes If YES, what years, what state(s), and what date did you return to Maine:____________________________________________________________________________ ____________________________________________________________________________________ NOTE: Any question that has not been answered completely and correctly will delay the tax clearance process. Please be specific. I authorize the Maine Gambling Control Board, their designees and the Maine State Police to share my social security number and tax history with Maine Revenue Services for tax background purposes. I also authorize Maine Revenue Services to release my tax history results back to the Maine Gambling Control Board, their Designees and the Maine State Police. Applicant Signature:___________________________________Date:___________________________ MRS Office Use Only Clearance Granted: ( Yes ( No If No, reason:___________________________________ ____________________________________________________________________________________ MRS Clearance Officer:________________________________ Date:____________________________ Tracer Needed: ( Yes ( No F107 Notes: (      FILENAME \p H:\ENFORCE\TAX CLEARANCES\Forms\Maine Gambling Control Board Tax Clearance Form 08-23-12.doc Created 8/23/12 (./<DEF_bcrs      E J ТТЗ~sesesYshh\5CJaJ jqhhHCJaJhhHCJaJhhCJaJ hCJhCJaJh\hCJaJhhCJaJhh0ECJaJh!CJaJh0ECJaJhO~lCJaJhhO~lCJaJhMCJaJhhO~l5CJaJ hhh L h0E5/FOPcrixkd$$IfTi40)z 04 iaf4T dh$Ifgd&P $Ifgd0E$a$gdZ rsxxx dh$Ifgdzkd$$IfTi40%)04 iaf4T k !  |hXXShG dh`gdQmIgdJ8dh^8`gdQmI & F 8 ^` gdQmIgd}kd.$$IfTi40%)04 iaf4ytTJ O Q W h      ! $ ' 4 8 B J O Z c h q w    $ % * + / 3 5 > S _ z  $ % & ײ׾ײקלבבhhJCJaJhh5CJaJhh LCJaJhh\5CJaJ jqhhHCJaJhh'(sCJaJhhCJaJhCJaJhhHCJaJhhCJaJ6 $ | % & 7 un-$h$d %d &d 'd N O P Q ^ha$gdQmI dh^gdQmI & F 8%^`%gdQmIh^hgdJ dh^gd^gdQmI & F 8 ^` gdQmIgd dh`gdQmI , 3 htvŧŧśzqh_WhMCJaJhV%66CJaJh@6CJaJh0E6CJaJh!6CJaJhhJ6CJaJhhJ5CJaJhhQmI5CJaJhCJaJhhJCJaJhhQmICJaJhh LCJaJhh\5CJaJ jqhhCJaJhhCJaJhh9CJaJ!uv= !#$hdh$d N ^hgdxhdh$d N ^hgd&Phd$d N ^hgdK#h$d N ^hgd$h$d N ^ha$gdh^hgdJ !25 !"ø߭ߌssskgkgkh^jh^U jqhhK#CJaJhhCJaJh&PCJaJhh|}CJaJ jqhh|}CJaJhh&PCJaJhhCJaJhh5CJaJhCJaJhxCJaJhhK#CJaJhhJCJaJhh\CJaJ("$%'(56幱hhK#CJaJhvhhvCJ aJ hCJ aJ h[gFCJ aJ h@CJ aJ mHnHujh[gFCJ UaJ h[gFh[gFCJ aJ jh[gFh[gFCJ UaJ jh^Uh^$&'hdh$d N ^hgdx61h/R :p/ =!"#$%h $$If!vh#vz#v :V i405z5 44 if4T$$If!vh#v#v:V i405544 if4T$$If!vh#v#v:V i4055/ 44 if4ytT^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH DA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List jj Z Table Grid7:V044 &PHeader  !4 @4 &PFooter  !H@"H H Balloon TextCJOJQJ^JaJ6U`16 g Hyperlink >*B*phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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