STATE OF CONNECTICUT DEPARTMENT OF REVENUE SERVICES Legal Division 25 Sigourney Street Hartford, CT 06106-5032 (Rev. 9/97) REQUEST FOR ISSUANCE OF A RULING LGL-006 Name of taxpayer Address of taxpayer Connecticut tax registration number, if any Federal employer identification number or social security number YES 1. Does this request involve a prospective (as opposed to a consummated) transaction? 2. Does this request involve an issue that is the same or similar to one: A. B. C. D. being considered by the Department in connection with an audit examination of this taxpayer? being appealed to the Appellate Division of the Department by this taxpayer? being litigated in the Connecticut courts by this taxpayer? being considered by the Department in connection with a claim for refund made by this taxpayer? NO r r r r r r r r r r r r r r r r r r r r 3. Is this taxpayer undergoing an audit examination by the Department with respect to any issue or tax? 4. Has this taxpayer been notified concerning a pending audit examination by the Department with respect to any issue or tax? 5. Does this request involve an issue that is clearly and adequately addressed by a statute, regulation or decision of the Connecticut or federal courts or by a declaratory ruling, ruling, Special Notice, Policy Statement or tax return instruction that has been issued by the Department? 6. Has the taxpayer previously been issued a ruling on the same or a similar issue by the Department? (If "yes", attach a copy of the ruling) 7. Has a representative been authorized to request the issuance of a ruling on behalf of this taxpayer? (If "yes" enter the name and address of the representative. The representative must be an individual or individuals and may not sign declaration below.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 8. Enter name and address to which the original of the ruling and other correspondence is to be mailed. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ DECLARATION Only an individual having personal knowledge of the facts may sign the declaration below. An authorized representative may not sign the declaration. If this taxpayer is a corporation, partnership or trust or estate, the individual signing the declaration on behalf of the taypayer must be a corporate officer, general partner or fiduciary, as the case may be. Under the penalty of false statement, I declare that I have personal knowledge of the facts involved in this request and that I have examined this request, including accompanying documents, and, to the best of my knowledge and belief, the facts presented in support of this request are true, correct and complete. __________________________________________________________________________________________ Signature __________________________________________________________________________________________ Print or Type Name ____________________________________ Date ____________________________________ Print or Type Title The procedures that a taxpayer or authorized representative must comply with in requesting the issuance of a ruling and the procedures that the Department follows in issuing a ruling are described in PS 91(6.2). To obtain a copy call 860-297-5962 or 1-800-382-9463 (in-state). Telecommunications Device for the Deaf (TDD/TT) users only call 860-297-4911. American LegalNet, Inc. www.FormsWorkflow.com