Form 775 - Request For Informal Conference - 2011
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1
2
3Alaska Department of Revenue
775
Request for Informal Conference
INSTRUCTIONS
Complete lines 1 - 11 with the information requested. You can find the FSN on the assessment or adjustment letter. Remember to include
a copy of the letter with the request. Check the box on line 12 to request an informal conference. Check also your preference for the
means by which the conference may be conducted. Check only the correspondence box if you want us to review what you submit with
the appeal and then issue a decision. Check the box on line 13 if you are filing a power of attorney.
You are required to explain the basis of the appeal on line 14. Specify adjustments and findings with which you disagree, the points on
which you intend to rely, and any facts on which you intend to rely that are different from those of the Department of Revenue. Attach
additional pages if you require more space. The person making the request must sign the form as provided on line 15. A representative
must have a power of attorney to execute this form on behalf of a taxpayer.
Mail the request to:
ALASKA DEPARTMENT OF REVENUE
TAX DIVISION, APPEALS
PO BOX 110420
JUNEAU AK 99811-0420
(PLEASE PRINT OR TYPE)
1 Taxpayer Name
6 EIN or SSN
7
FSN(s)
2 Mailing Address
8 Contact Person
3 Additional Address Information
9 Contact Person’s Email Address
4 City, State, Zip Code
10 Daytime Contact Phone and Fax Numbers
5 Tax Type and Periods
11 Date of Letter of Assessment or Denial of Refund (attach Copy)
12
Notice of appeal is hereby given to the assessment or claim denial action of the Department of Revenue in fixing the amount of a tax or
penalty. An informal conference with an Appeals Officer is requested by: [check appropriate box(es)]
Telephone
Correspondence (My arguments and evidence are included.)
In Person at the Tax Division’s Anchorage Office
13
Notice of representation by another person on my behalf is hereby given and a power of attorney form is enclosed.
14 Explanation
15 Under penalty of unsworn falsification, i declare that i have examined this document, including accompanying schedules and statements, and to
the best of my knowledge and belief it is true, correct and complete.
SIGNATURE (An officer must sign for a corporation, partner-
DATE
ship or trust)
PRINTED NAME
TITLE, If request for Appeal is for a Corporation, Partnership or Trust
775
0405-775 Rev 02/11
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