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Contractor Signature Printed Name Title If tax clearance is being requested on behalf of a corporation/LLC/partnership must be signed by an officer/member/partner. Send completed form by facsimile to the Department of Revenue at 907 465-2375 DEPARTMENT USE ONLY The above applicant is current on all taxes penalties and interest due and is in good standing with the Alaska Department of Revenue. Alaska Department of Revenue TAX CLEARANCE REQUEST FORM Contractor Name Project Name and Number EIN/SSN Mailing Address City/State/Zip Code I hereby authorize the Alaska Department of Revenue to release to Department of Transportation State of Alaska Name of Department or Agency whose facsimile number is confirmation that all taxes penalties and interest due the Department of Revenue have been paid and that there are no outstanding amounts due. Contractor Signature Printed Name Title If tax clearance is being requested on behalf of a corporation/LLC/partnership must be signed by an officer/member/partner. Send completed form by facsimile to the Department of Revenue at 907 465-2375 DEPARTMENT USE ONLY The above applicant is current on all taxes penalties and interest due and is in good standing with the Alaska Department of Revenue. and is not in good standing with the Alaska Department of Revenue. Department of Revenue Representative TaxClearanceRequestForm Rev09/10 JG DOT Date. Send completed form by facsimile to the Department of Revenue at 907 465-2375 DEPARTMENT USE ONLY The above applicant is current on all taxes penalties and interest due and is in good standing with the Alaska Department of Revenue. and is not in good standing with the Alaska Department of Revenue. Department of Revenue Representative TaxClearanceRequestForm Rev09/10 JG DOT Date.

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