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Printable Form 4421 Winston–Salem North Carolina: What You Should Know
Note: For all income received that is NOT from tobacco, this form is no longer required. In accordance with IRS Publication 537, “Information To Claim an Excess Benefit,” I am submitting a Form TTB-4583 to verify all statements in my Declaration of Tobacco Use or Non-Tobacco Use form. By signing and returning this form, I affirm that I have used tobacco only for ceremonial, religious, or personal purposes and have never been convicted of a Federal or State offense under the Controlled Substances Act, 21 U.S.C. 801 et seq., or the Tobacco Control Act, 21 U.S.C.A. § 301 et seq. If you are using Form TTB-4583 to establish, update, amend, or revoke a previous-year tax return, you should complete, sign and date it. Then, attach a signed copy to your return. You may also ask the Tax Court for confirmation at TAX COURT RETROGRADE. By checking I understand and agree that I will take a credit against the return, and that I will complete the Form 2555 (Additional Medicare Tax Form). By checking “YES”, I affirm that I am eligible to receive an excess benefit from the excess benefit credit, and I have consulted with the appropriate TT officer on the matter. By checking “NO”, I have not consulted with the appropriate TT officer on the matter. By checking “NO”, I am not eligible for an excess benefit under §54.3100-9(h)(3) of the Regulations. If you are using the above form to establish, update, amend, or revoke a previous-year tax return, you should complete, sign and date it. Then, attach a signed copy to your return. You may also ask the Tax Court for confirmation at TTB-4579 RETROGRADE or TAX COURT RETROGRADE. I am attaching my declaration of tobacco use/non-tobacco use form and completed form to my return.
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