Form Boa-1 - Board Of Appeals Petition Page 4
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4Part 4: Taxpayer or petitioner must sign below
I state that I have examined this petition and, to the best of my knowledge, it is true, correct, and complete.
Please sign and date here:
___________________________________________________________________
___ ___/___ ___/___ ___ ___ ___
Date:
Taxpayer’s signature (if corporation, duly authorized officer’s signature)
Month
Day
Year
Phone no.(____)___________
Please print or type clearly:
___________________________________________________________________
Taxpayer’s name (if corporation, please print duly authorized officer’s name)
Part 5: Sign the waiver
Explanation of waiver:
Before the Board of Appeals accepts jurisdiction, the following waiver of statutes of limitations must be signed by the petition-
ing taxpayer personally, by a duly authorized officer of a petitioning corporation, or by a taxpayer’s representative
under a valid power of attorney. This waiver will be valid only if the Board of Appeals accepts jurisdiction in this case. If the
board accepts jurisdiction, a docket number will be assigned, and this waiver will be executed by the board on behalf of the
Department of Revenue. The waiver affects open periods only, having no effect on closed periods, or periods for which
assessments have been issued and for which the liability is final.
Waiver of Statute of Limitations
In order to allow time to review the taxpayer’s petition for relief by the Illinois Department of Revenue Board of Appeals, the
undersigned expressly agrees to extend the running of any and all statutes of limitations regarding the collection of any tax,
penalty or interest for the periods of time in which the petition is being considered by the Board. This waiver applies only to
collections action, and in no way is meant to reopen any periods or collections activities barred by the passing of any previously
expired statutes of limitations.
Taxpayer:
___________________________________________________________________
___ ___/___ ___/___ ___ ___ ___
Date:
Taxpayer’s signature (if corporation, duly authorized officer’s signature)
Month
Day
Year
___________________________________________________________________
___ ___/___ ___/___ ___ ___ ___
Date:
Taxpayer’s representative’s signature (if duly authorized under power of attorney)
Month
Day
Year
Illinois Department of Revenue:
___________________________________________________________________
___ ___/___ ___/___ ___ ___ ___
Date:
Director of Revenue
Month
Day
Year
Send the original petition, a copy of the petition, notices of deficiency/tax liability, and relevant documents. If this petition is an
“offer in compromise,” include copies of your last three federal and state income tax returns and all schedules, bank statements
from all of your bank accounts summarizing the last six months’ activity, a current financial statement (BOA-4, Financial Infor-
mation for Individuals, or BOA-5, Financial Information for Businesses), and your last two paycheck vouchers.
Mail to:
ILLINOIS DEPARTMENT OF REVENUE
Questions? Call: 312 814-3004
BOARD OF APPEALS
weekdays between 8:30 a.m. and 5:00 p.m.
JAMES R THOMPSON CENTER
Fax: 312 814-3055
100 W RANDOLPH ST
SUITE 7-339
CHICAGO IL 60601-3274
BOA-1 (R-1/01)
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