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).