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Excel - Ohio Department of Taxation

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					                                Application for Extension Request
                          Ohio 2011 Annual Statement of Gross Receipts
                              Telephone Number (614) 466-7371                       Fax Number (614) 752-2496

Company Name:                                                                                      FEIN:

Person Req. Ext:                                                     E-mail Address:

Telephone Number:                                             Fax Number:                                        Date:

The above referenced public utility desires an extension for the filing of it's Annual Statement of
Gross Receipts for a period of:

                             15 Days                                                      30 Days

                             45 Days*                                                     60 Days*

*An extension beyond 30 days must provide an extenuating reason in the space provided below.

      Extenuating Reason(s):




An extension can only be granted if our office receives the request by August 1, 2011. Confirmation of the
extension will be sent via the fax number provided above within two business days of receipt (mailed if fax
number is not provided). Fax the extension request to the Public Utility Tax Section at (614) 752-2496 or
mail your extension to:

                                               Ohio Department of Taxation
                                               Public Utility Tax Section
                                               P. O. Box 530
                                               Columbus, OH 43216-0530



                       Confirmation of Extension - For use by the Public Utility Tax Section Only

                     Your extension request has been approved                                  Days         **Due by

                     Your extension request was denied because



                           Tax Agent/Supervisor Signature                                      Date

** "Due by" or "receives" means actual receipt of the document by the Department of Taxation on or before that date (not a mailing date).

				
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