Document 6437153

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**** txprid= 999 99 9999 name1= JOHN TAXPAYER name2= street= 100 CAMBRIDGE ST citystatezip= BOSTON, MA 02114 noticecode= 00250 noticedate= 04/12/11 ****
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Notice Date: April 16, 2011
MASSACHUSETTS DEPT. OF REVENUE
Taxpayer ID Number:
PO BOX 7021
BOSTON, MA 02204
Bill Number:
PAYMENT AGREEMENT REMINDER
Total Amount Due:
$4,122.64
Payment Due Date:
April 28, 2011
Case Number:
001
00250 v. 04/12/11
Customer Service Bureau
Telephone: (617) 887-6367
XXX-XX-9999
0439 9999 9999
**** billno= 0439 9999 9999 ****
—’’“˜
401C
E
1 I
JOHN TAXPAYER
100 CAMBRIDGE ST
BOSTON MA 02114
Your monthly payment is now due...
PL
As part of your agreement to pay the taxes you owe in installments, the Massachusetts Department of
Revenue will send you this reminder each month. These reminders will only show the remaining balance
due on your agreement.
You must make the monthly minimum payments due to keep your account in good standing. You may also
pay more than the minimum amount due to reduce the total liability. Interest and penalties continue to accrue
until the liability is paid in full.
Please note: Monthly EFT payments will be withdrawn on the second to last Friday of each month.
If you do not make the required payments, this agreement will be terminated. For additional details on this
agreement, see the reverse side of this page.
M
If you have any questions...

CUT HERE AND RETURN THE COUPON BELOW IN THE ENVELOPE PROVIDED
Payment
Coupon
JOHN TAXPAYER
100 CAMBRIDGE ST
BOSTON MA 02114
Your payment must
be postmarked by
April 28, 2011
Taxpayer ID Number:
Bill Number:
City
Home Phone (
State
)
Zip
Work Phone (
)
0439 9999 9999
Total Amount Due:
$4,122.64
$
Write your Taxpayer ID # on your check or money order and
make it payable to:
Commonwealth of Massachusetts
1 I
Case Number: 001
Apt No.
999 99 9999
April 28, 2011
Please complete only if your address or phone has changed.
Street
Page 1 of 4
Payment Due Date:
Enter Amount
Enclosed
401C

00250 v. 04/12/11
SA
Please call the Customer Service Bureau (617) 887-6367 or toll-free in Massachusetts at
1-800-392-6089.
M
A
I
L
T
O
Massachusetts Department of Revenue
P. O. Box 7065
Boston, MA 02204-7065
999999999200043999999999000004122642
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