PENALTY WAIVER REQUEST FORM
Complete this form to request a waiver of penalties assessed for the delinquent filing of a tax and/or licensing fee
return. Submit to: Revenue Office, 144 Tichenor Avenue, Suite 6, Auburn, Alabama 36830. Before completing
this form, please read instructions detailed on back of this form.
BUSINESS INFORMATION
Business Name: ____________________________________________________ Customer Nbr: __________
Name/Title of Person Requesting Waiver: _______________________________________________________
Business Address: __________________________________________________________________________
Phone: __________________ Fax: __________________ Email: __________________________________
TAX/LICENSING PENALTY TYPE (Check the tax/licensing type on which the penalty was assessed)
Period (month/year) Penalty Assessed: ______________________ Amount of Penalty: __________________
Sales Tax Use Tax Rental/Leasing Tax Lodging Tax Liquor Tax Occupational License Fee
Contractors/Subcontractors License Fee Motor Fuel Tax Wholesale Wine Tax Business License Liquor
License
REASON FOR REQUEST OF WAIVER
Date of Request: ________________
Death or major illness of or an accident involving a sole proprietor causing serious bodily injury that in either case
resulted in the sole proprietor being unable to purchase the license, file tax/licensing fee returns, or operate the
business during the ten (10) days preceding the due date of the license fee and/or tax
Name of Individual: _________________________________________________________________________
Position/Title with Business: __________________________________________________________________
Date of Death/Illness/Accident: ________________________________________________________________
Explanation of how event prevented compliance: __________________________________________________
__________________________________________________________________________________________
Natural disaster, fire, explosion, or accident that caused the closing or temporary cessation of the business of the
taxpayer during the ten (10) days preceding the due date of the license fee and/or tax
Date and Type of Event: _____________________________________________________________________
Explanation of how event prevented compliance: __________________________________________________
__________________________________________________________________________________________
Reliance on erroneous advice of an employee or agent of the Revenue Office of the City of Auburn or its designee
given in writing or by electronic mail (attach documentation to support)
Name of Employee/Agent: _________________________________ Date Advice Received: ______________
Explanation of how event prevented compliance: __________________________________________________
__________________________________________________________________________________________
Other (Attach documentation to support)
Provide explanation preventing compliance: __________________________________________________
__________________________________________________________________________________________
If additional information is needed to document your request, please attach a separate sheet.