Form Apls102f - Notice Of Referral To The Office Of Dispute Resolution printable pdf download

MONTANA

APLS102F

Rev. 10-08

Notice of Referral to the Ofﬁ ce of Dispute Resolution

You may appeal a decision made by the Department of Revenue based upon the informal review of your Statement of

Account, or for centrally assessed property’s ﬁ nal Appraisal Report. You must ﬁ le this Notice of Referral within 15 days

of the date on the notice of the determination from the department. Please attach a copy of your Request for Informal

Review (Form APLS101F) or detailed letter explaining your objection.

Name/Address

Account ID: ___________________________________

___________________________________________

Following my informal review, I hereby make application to the Ofﬁ ce of Dispute Resolution of the Department of Revenue

for review on this _____________________________________ day of _________________________ , 20 ____ .

Please indicate the type of tax and tax periods you are

E-mail ________________________________________

disputing (centrally assessed property, corporation, natural

County of ______________________________________

resource, income, etc.): ___________________________

Account Number ________________________________

______________________________________________

FEIN _______ - ________________________ or

______________________________________________

SSN _____________ - __________- __________________

______________________________________________

Owner/Business name and address: _________________

Legal description (if applicable): _____________________

______________________________________________

_______________________________________________

______________________________________________

_______________________________________________

______________________________________________

_______________________________________________

______________________________________________

Person ﬁ ling this form (if different from above): _________

Phone Number ( ________ ) _________ - ____________

______________________________________________

Fax Number

( ________ ) _________ - ____________

______________________________________________

You may have someone represent you in this matter. If you want someone to represent you, please provide us with a copy

of a completed Department of Revenue Power of Attorney form. You can get this form on our website at mt.gov/revenue

or by calling us toll free at (866) 859-2254 (in Helena, 444-6900).

Mail to: Montana Department of Revenue, PO Box 7701, Helena, MT 59604-7701

FOR DEPARTMENT USE ONLY

Date received by the Ofﬁ ce of Dispute Resolution __________________________________________________

Was a Request for Informal Review (Form APLS101F) ﬁ led?

Yes

If yes, date of review _________________________________________________________________________

Person receiving this form _____________________________________ Title/Role ________________________

577

Form Apls102f - Notice Of Referral To The Office Of Dispute Resolution

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