Request For Conciliation Conference Form - New York City Department Of Finance - Draft
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1
2REQUEST FOR CONCILIATION CONFERENCE
F I N A N C E
D D R R A A F F T T
NEW
YORK
G
COMPLETE ALL APPLICABLE SECTIONS
Print or type
Name of Taxpayer
EMPLOYER IDENTIFICATION NUMBER
Name of Contact Person (corporations or partnerships)
Address (number and street)
SOCIAL SECURITY NUMBER
City and State
Zip Code
Business Telephone Number
Name of Taxpayer's Representative, if any
EMPLOYER IDENTIFICATION NUMBER
Relationship to Taxpayer
Address (number and street)
SOCIAL SECURITY NUMBER
City and State
Zip Code
Business Telephone Number
Check if you have filed a petition with the NYC Tax Appeals Tribunal in this matter. IF YOU HAVE FILED A PETITION, DO NOT FILE THIS
I I
REQUEST FORM. (See reverse side.)
A DULY EXECUTED POWER OF ATTORNEY MUST ACCOMPANY THIS REQUEST
if the taxpayer is being represented by, or this request
is signed by, someone other than: (i) a duly authorized officer of a corporate taxpayer; (ii) a general partner of a taxpayer that is a partnership; (iii) an adult
spouse, parent, guardian or the person who prepared the return in the case of a taxpayer who is a minor or who is physically or mentally incapable of rep-
resenting him or herself.
Enter the tax type involved: _______________________________________
M
Enter the case number
M
Enter the taxable year(s) or period(s): _______________________________
I I
I I
REDETERMINATION OF DEFICIENCY IS REQUESTED.
REFUND IS REQUESTED.
A COPY OF
A COPY OF THE NOTICE BEING PROTESTED
THE NOTICE BEING PROTESTED MUST BE SUBMITTED WITH THIS REQUEST.
MUST BE SUBMITTED WITH THIS REQUEST.
Date of Notice of Determination:
Date of Notice of Disallowance:
No Notice of Disallowance has been received
Principal due:
$ ______________________
¡
but a claim for refund was filed on:
(This request may be filed in a GCT or UBT
Interest due:
$ ______________________
case if at least six months have passed
since the claim was filed and no notice of disal-
Penalty due:
$ ______________________
lowance has been received.)
Total amount on Notice
$ ______________________
Amount of refund requested:
$ ______________________
State the basis for making this claim. Include all relevant facts. (Attach additional sheets if more space is required.)
This request is made with the knowledge that a willfully false representation is a misdemeanor under
Mail completed request form to:
Section 11-4004 of the NYC Administrative Code.
Bureau of Conciliation
S
IGN
¡
New York City Department of Finance
HERE
L Signature of Taxpayer or Representative
345 Adams Street, 3rd Floor
Brooklyn, NY 11201
L Name and Title (please print or type)
L Date
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