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Gaming Request Form For Appeal

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Department of Revenue

Tax Division

PO Box 110420

Juneau, AK 99811-0420

GAMING REQUEST FOR APPEAL

Department Use Only

Please Print or Type

Name of Permittee:

Permit No.:

Name of Operator:

License No.:

Name of Pull-Tab Distributor:

License No.:

Mailing Address:

Name of Primary or Contact Person:

Street No. or PO Box

Daytime Telephone Number:

Ext. No.

City, Municipality, State and Zip Code

Fax Number:

Date of Notice of Assessment, Denial of Permit or

Type of Assessment or Action: (check appropriate box)

License, Suspension or Revocation of Permit or

3% Pull-Tab Tax

Denial of Permit or License

License or Informal Conference Decision.

1% Additional Fees

Order of Prohibition

Permit or License Fees

Informal Conference Decision

Suspension or Revocation of Permit / License

YES

Do you request an informal conference? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(This does not apply if this is an appeal from an informal conference decision.)

If yes, please check your preference:

Telephone

Correspondence; submit argument and evidence in writing with this appeal

Juneau

In person at:

Anchorage

Do you request a formal hearing to appeal an informal conference decision)? . . . . . . . . . . . . . . . . . . . . . . . . .

Do you wish to be represented by an attorney, CPA, or other representative? . . . . . . . . . . . . . . . . . . . . . .

(If yes, please complete the attached Power of Attorney, Form 04-0852.)

EXPLANATION OF REQUEST FOR APPEAL: Please state: (a) action with which you disagree; (b) facts; (c) law; (d) agreed findings.

(See instructions on back.) If additional space is needed, you may attach additional sheets.

Under penalty of perjury, I declare that I have examined this request for appeal, including accompanying schedules and statements, and to the best of my knowledg

and belief they are true, correct and complete. If prepared by a person other than the primary member in charge of games or officer of permittee organization, operato

or pull-tab distributor, the declaration is b

Date

Signature

Title

Date

Preparer's Printed Name and Signature

Title

Preparer's Address

Preparer's Daytime Telephone

Form 04-0851 Webform (Rev 02/06)