Form MT-170 Fillable Waste Tire Management Fee Quarterly Return
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

Compute additional charges $2 25 per tire (: multiple) Unchecked (: single) Unchecked (8/11) (add lines 3 and 4) 5 (checkbox) Unchecked (checkbox) Unchecked (line 1 x line 2) 3 (PTIN) if you have one; if not you must enter your social security number (RALs) and refund anticipation checks (RACs) to register electronically with (see instr ) (see instructions) 4 (see Need help?) (SSN) (PTIN information is available at www irs gov ) (Tax Law section 1085 (a)(1)(B)) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 1 Number of tires sold 1142 and 1415 of that Law; and may require disclosure of social security 2 Fee due per tire ($2 50 3 Net amount of fees due 4 Penalties and interest 5 Total amount due 6 Amount remitted with this A If you do not file a return when due add to the net fees 5% per above (Tax Law section 1085 (a)) add to the net fees % per month up to a total of 25% (Tax Law addition you must enter your federal preparer tax identification number additional charge in item A above cannot be less than the smaller Address (number and street or rural route) after amount and indicate the number of locations covered by this report Please type or and when authorized by law for certain tax offset and exchange of tax are as follows: are required to have one (Information on the New York State Tax Preparer are subject to the fee assistant treasurer chief accounting officer or other officer authorized by Attach check or money order payable to: Commissioner of Taxation and authority for your calculation of the net amount (2) there is adequate Authorized B If you do not file a return within 60 days of the due date the BINGHAMTON NY 13902 4100 box on the front of the return Business name Business Tax Information Center: (518) 457 5342 C If you do not pay the net fees shown on a return when due certain paid tax return preparers and facilitators of refund anticipation loans City village or post office State ZIP code Complete back Completing your return conducted by a trustee or trustees must be signed by a person authorized criminal penalties or both under the Tax Law D The total of the additional charges in items A and C may not date full payment is made December 1 through February 28 (29) March 31 Did you sell tires during this quarter? If you did not sell any disclosure on the return or in an attached statement or (3) there was Due date for due to reasonable cause and not due to willful neglect If you think you are during the quarterly period enter 0 on lines 1 3 4 5 and 6 and sign the E mail address of individual preparing this document enforcement evaluation of the effectiveness of certain employment and entitled to retain a statutory allowance of $ 25 per tire from fees collected exceed 5% for any one month except as provided for in item B explaining the delay in filing payment or both (Tax Law section 1085) explanation Failure to provide the required information may subject you to civil or fee $ 25 allowance) 2 $ 2 25 Fee for payments returned by banks fee for this business at this/these location(s) mark an X in the Final return fee please refer to TSB M 04(2)M Waste Tire Management Fee Changes fees you report is understated by 10% or $5 000 whichever is greater filing return Final return Amended return Did not sell any tires in this quarter Finance Firm s EIN Firm s name (or yours if self employed) for 2004 for any purpose mark an X in the Amended return box on the front of the for late filing and late payment on the net amount of fees due minus any For more detailed information about which sales of tires are subject to this General information help? However if an electronic payment is returned as a result of an error by I hereby certify that this return is true and correct I make these statements with the knowledge that knowingly making a false or fraudulent identification number If an outside individual or firm prepared the return all applicable entries If line 5 and line 6 are not the same amount attach an If you did not sell any tires for which you were required to collect the fee If you do not pay the entire net amount If you file separate sales tax returns for each location file a separate waste If you understate the net amount of fees due If the net amount of imposed by Environmental Conservation Law section 27 1913 in the area provided and attach an explanation If you have overpaid the in the paid preparer section must be completed including identification Information concerning quarterly wages paid to employees is provided information programs as well as for any other lawful purpose Interest Is this an amended return? If you are filing an amended return Is this return for multiple locations? If you are a tire retailer Is this your final return? If you are filing the final return for this June 1 through August 31 September 30 least three years Line 1 Enter the number of tires sold during the quarterly period that Line 2 This preprinted amount represents the portion of the fee per tire Line 3 Multiply the number of tires entered on line 1 by the fee due of Line 4 If penalties and interest apply (see below) enter the appropriate Line instructions Mail to: management fee during the quarter March 1 through May 31 June 30 Mark an X in the box if: money order or electronic payment is returned by a bank for nonpayment month up to 25% (Tax Law section 1085(a)(1)(A)) MT 170 MT 170 (8/11) (back) Need help? New York State Department of Taxation and Finance New York State The waste tire management fee does not apply to sales of New York tax preparer registration identification number (NYTPRIN) if you no sales of tires for which you were required to collect the waste tire not liable for these additional charges attach a statement to your return not limited to sections 5 a 171 171 a 287 308 429 475 505 697 1096 Note: You may compute your penalty and interest by accessing our Web numbers (see Paid preparer identification numbers) Failure to sign the numbers pursuant to 42 USC 405(c)(2)(C)(i) NYS TAX DEPARTMENT NYS Tax Department W A Harriman Campus Albany NY 12227; of $100 or 100% of the net fees required to be shown on the return of fees due (line 3) on or before the due date you must pay interest on On your check write Form MT 170 your sales tax identification number and the other tax document associated with the returned payment Paid preparer identification numbers New York State Tax Law requires payment is returned we will send a separate bill for $50 for each return or payment made on or before the due date Penalties Penalties and interest period for which you are reporting person E mail address of authorized person personal information pursuant to the New York State Tax Law including but PO BOX 4100 preparer Preparer s NYTPRIN Preparer s PTIN or SSN print (use black ink only; no red or other color ink or pencils please) Print this return 2 sided complete front and back and detach here Privacy notification Private delivery services To use a private delivery service see Publication 55 Designated Private Delivery Services Quarterly period Quarterly period ending Quarterly Return Quarterly Return (with instructions) Read instructions before completing return reasonable cause for the understatement (see Tax Law section 1085(k)) Registration Program is available on our Web site (see Need help?) ) In return return 6 return enter the ending date of the quarter and the corrected information return for all locations file a combined waste tire management fee return for return will delay the processing of any refunds and may result in penalties sales and tires sold for resale you must file a return even when you had Sales tax section 1085 (a)(2)) self propelled or towed vehicles that could be registered for any reason September 1 through November 30 December 31 sign and date your return If you sold tires but did not sell any tires that you Signature Signature of authorized person Official title Signature of individual preparing this document Address Single location Multiple locations (enter number): site or you may call and we will compute the penalty and interest for you spare tires whether they are full size or for emergency use only speech disabilities using a TTY): (518) 485 5082 State ZIP code statement on this document is a misdemeanor under section 210 45 of the Penal Law subject to fee 1 Tax Department will mail you a refund If you have any questions see Need telephone (518) 457 5181 Telephone number Text Telephone (TTY) Hotline(for persons with hearing and the amount of the underpayment from the due date of the return to the the bank or the department the department won t charge the fee If your The Commissioner of Taxation and Finance may collect and maintain The fee also applies to new tires sold with a new or used vehicle including The law allows the Tax Department to charge a $50 fee when a check The return must be certified by the president vice president treasurer The return of an association publicly traded partnership or business the seller is entitled to retain The Tax Department is responsible for administering the fee which is the Tax Department When completing this section you must enter your The Tax Law requires that you keep a copy of your completed return for at the taxpayer corporation The waste tire fee applies to new tires sold for use on nearly all This information is maintained by the Manager of Document Management This information will be used to determine and administer tax liabilities This return is for (mark an X in one): those same locations Mark an X in the Multiple locations box on the return Tire Management Fee Changes for 2004 for information about which tires tire management fee return for those same locations Tire sellers must collect a fee of $2 50 on each new tire sold within tires during this quarter mark an X in the box on the front of the return and to act for the association publicly traded partnership or business to certain state agencies for purposes of fraud prevention support To order forms and publications: (518) 457 5431 training programs and other purposes authorized by law used or recapped tires mail order sales or sales for resale The sellers are Visit our Web site at www tax ny gov getinformationandmanageyourtaxesonline checkfornewonlineservicesandfeatures Waste Tire Management Fee WASTE TIRE MANAGEMENT FEE were required to collect the fee on see the instructions for line 1 were subject to the waste tire management fee See TSB M 04(2)M Waste When to file The quarterly reporting periods and return due dates Where to file Mail to: NYS TAX DEPARTMENT which is payable to the department after deducting the statutory allowance Who must file If you sell tires including recapped tires mail order with more than one location in the state and you file a combined sales tax You may not be liable for penalties if your failure to file or remit the fees is You may not be liable for this penalty if (1) there is or was substantial you must pay a penalty of 10% of the amount of understated fees