Request For Conciliation Conference - New York City Department Of Finance - 2017 - Draft
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1
2REQUEST FOR CONCILIATION CONFERENCE
TM
COMPLETE ALL APPLICABLE SECTIONS
Department of Finance
Mail completed request form in duplicate to:
NYC Department of Finance, Bureau of Conciliation, 345 Adams Street, 3rd Floor, Brooklyn, NY 11201
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
Country (if not US)
Business Telephone Number:
Email Address: (We will contact you by email to schedule a conference and to request additional information, if needed)
Name of Taxpayer's Representative, if any:
Relationship to Taxpayer:
Address: (number and street)
City and State:
Zip Code
Country (if not US)
Business Telephone Number:
Email Address: (We will contact you by email to schedule a conference and to request additional information, if needed)
IF YOU HAVE FILED A PETITION, DO NOT FILE THIS 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, registered domestic partner, 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 representing him or herself.
Enter the tax type involved: _______________________________________
Enter Audit Case ID
t
t
Enter the taxable year(s) or period(s): _______________________________
n
n
REDETERMINATION OF DEFICIENCY IS REQUESTED.
REFUND IS REQUESTED.
A COPY OF THE NOTICE OF DETERMINATION
A COPY OF THE NOTICE OF DISALLOWANCE
BEING PROTESTED MUST BE SUBMITTED
BEING PROTESTED MUST BE SUBMITTED
WITH THIS REQUEST
WITH THIS REQUEST
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-
-
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Date of Notice of Determination:
Date of Notice of Disallowance.................
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-
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 disallowance has
Penalty due:
$ ______________________
been received.) Please include a copy of the claim.
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 Section 11-4004 of the NYC Administrative Code.
S
IGN
:
HERE
Signature of Taxpayer or Representative
PRINT
OR
:
TYPE
Name
Title
Date
Request for Conc. Conf. 2017
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