Form M-911 is a document that is used by the police to report an incident. This form is also known as a Police Incident Report (PIR). It is used to record information about the occurrence, including the name and contact information of the reporting party, details of the incident, and any follow up actions that were taken. Anyone can fill out a Form M-911, but it is most commonly used by law enforcement officials. Having this form on hand can help ensure that all necessary information is collected in the event of an incident.
| Question | Answer |
|---|---|
| Form Name | Form M 911 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | mass form 911, mass form m911, ma hardship, ma form m 911 |
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Section A. Taxpayer information
Name of taxpayer, as shown on tax form |
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Taxpayer’s Social Security number |
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Name of spouse |
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Spouse’s Social Security number |
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Mailing address |
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City/Town |
State |
Zip |
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Telephone number |
Federal Identification number (if a business) |
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Section B. Income sources
Types of government assistance you are currently receiving (fill in all that apply):
Social Security income |
Food stamps/SNAP/WIC |
Social Security Disability income |
Heating/Fuel assistance |
Unemployment benefits |
Veterans disability benefits |
Housing assistance |
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Section C. Hardship circumstances
indicate any immediate hardship circumstances (fill in all that apply):
Incarceration |
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Homelessness |
Hospitalization and/or hospice |
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Other |
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Section D. Hardship explanation
Explain in detail why you are applying for hardship. Attach additional pages if necessary. Nte The Department of Revenue may request additional doc- umentation in support of your claim.
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Signature of spouse |
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Rev. 8/19
Form
When to Use This Form
If you have an immediate hardship as the result of a bank levy, wage levy of license revocations, call the Hardship Unit at 617-
Use this form to apply for relief from a significant hardship which may have already occurred or is about to occur if the Department of Revenue (DOR) takes or fails to take certain actions. A signifi- cant hardship means not being able to provide the necessities of life for you or your family. Examples of such necessities include, but are not limited to: food, shelter, clothing, or medical care.
Requesting a Payment Agreement
If you are able to make regular payments, you can request a pay- ment agreement online through Mass Tax Connect at mass.gov/masstaxconnect.
Disputing Tax or Penalties
Do not use this application to request a change in the amount of tax you owe. If you disagree with the amount of tax or penalty as- sessed, you may file dispute online through Mass Tax Connect at mass.gov/masstaxconnect. You may also file a dispute on paper utilizing a Form ABT. For more information about filing a dispute or if you have questions about a bill that you don’t understand, please call the Contact Center at (617)
Taxpayer Information
Enter your name and social security number, your spouse’s name and social security number if applicable and your current mailing address.
Provide a telephone number where you can be reached during the day and an email address.
If you are responsible for taxes related to a closed business and you are requesting hardship relief from a business tax liability, enter the Federal Identification number (FID) of the business.
Income Sources
Indicate any form of government assistance you currently receive. Attach documentation where applicable.
Any additional sources of income must be documented and at- tached to this form.
Hardship Circumstances
Indicate any circumstances that may be contributing to your inabil- ity to earn income or pay your tax liability.
Attach any available documentation that would assist us in our de- termination of your hardship request.
Hardship Explanation
Power of Attorney
If you wish to have a representative act on your behalf, you must complete Form
Where to Submit This Form
Mail this application to Massachusetts Department of Revenue, PO Box 7021, Boston, MA02204 Attn: Hardship or fax to
Hardship Approval Details
*Hardship approval does not eliminate your tax liability;
*Hardship approval does not reduce, stop or eliminate the statu- tory accrual of penalty and/or interest associated with your tax lia- bility;
*Hardship approval does not release nor stop the issuance of state tax liens; and
*Hardship approval does not stop the intercept/offset program.
Hardship Approval Limits Some Administrative Collection Action
*Hardship approval temporarily stops automated bank levy action;
*Hardship approval temporarily stops automated wage garnish- ments;
*Hardship approval may restore a suspended Massachusetts state driver’s license and/or vehicle registration;
*Hardship approval may allow for the renewal of a professional li- cense; and
*Hardship approval may remove a taxpayer from the state’s Public Disclosure List.
Explain the nature of the hardship affecting you or your family. At- tach additional pages if necessary.