Form 76-005 - Petition For Waiver Or Variance - 2013 Page 2
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2Petition for Waiver or Variance, page 2
Does the Petitioner have any prior activity with the Department in regard to this request for waiver or variance?
Yes
No
If yes, please describe: (such as audits, notices of assessment, refund claims, contested case hearings, or
investigative reports relating to this activity for the past 5 years.)
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Does the Petitioner know of any cases of waivers that are either already decided or applied for with the Department that
are similar to this request for waiver or variance?
Yes - List cases below.
No
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Please provide the names, addresses, and phone numbers for those persons or organizations that will be adversely
affected by the granting of this waiver or variance, including any public agency or political subdivision:
______________________________________
____________________________________________
______________________________________
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Please provide the names, addresses, and phone numbers for those persons or organizations that have knowledge of
relevant facts of this waiver or variance:
________________________________________
____________________________________________
________________________________________
____________________________________________
________________________________________
____________________________________________
________________________________________
____________________________________________
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Petitioners must obtain a signed release from persons or organizations with knowledge of relevant facts for this waiver or
variance.
If the Petitioner wants identifying details deleted from the public file and the deletions are authorized by statute, each
detail must be listed with the statutory authority for the deletion.
Name of Petitioner: ________________________________________________
(Please Print)
By signing this document below, the Petitioner is attesting to the truth and accuracy of the information set forth in this
document.
Signature of Petitioner: _____________________________________________ Date: __________________________
MAIL TO:
Policy Section, Iowa Department of Revenue, PO Box 14457, Des Moines IA 50306 - 3457
76-005b (07/01/13)
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