Georgetown Scott County Revenue Commission

ONE- TIME COURTESY PENALTY WAIVER REQUEST

FEIN/SSN:

Taxpayer/Business Account Name:

I am writing to request to use the ONE-TIME ONLY courtesy late filing/payment penalty abatement waiver for the above named account for the following tax periods/return:

I understand that the maximum amount of this waiver is $75.00 and that no portion of that amount can be used as a future account credit. This is a one-time courtesy waiver that can only be applied to one delinquent return.

By submitting this request, I understand and acknowledge that this courtesy waiver can only be used once and after that all subsequent abatement and/or waiver requests must be submitted by using the Consideration of Penalty and Interest Abatement Request policy of the Georgetown-Scott County Revenue Commission.

Printed Name:

Email:

Signature:

Sign here

FEIN/SSN: *

Taxpayer/Business Account Name: *

I am writing to request to use the ONE-TIME ONLY courtesy late filing/payment penalty abatement waiver for the above named account for the following tax periods/return: *

Printed Name: *

Email: *

Signature: *

Date: *