Form Apls101f - Request For Informal Review
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1MONTANA
Clear Form
APLS101F
Rev. 10-08
Request for Informal Review
For issues concerning a fi rst notice of an adjustment of tax made by the department, this form must be fi led within 30
days of the date of the Statement of Account or other notice of adjustment.
For issues concerning appraisal reports for Centrally Assessed Property, this form must be fi led within 15 days of the
date of the appraisal report.
Taxpayer or Owner/Business Name and Address
Account ID: ___________________________________
______________________________________________
FEIN/SSN: ____________________________________
______________________________________________
Other Account Number (such as: Lodging Facility Use Tax
number):
______________________________________________
_____________________________________________
Please indicate the type of tax and the tax periods you are disputing:
Type of Tax
Tax Periods:
Type of Tax
Tax Periods:
Centrally Assessed Property
Miscellaneous Taxes
Corporation License Tax
Natural Resource Taxes
Individual Income Tax
Withholding Tax
Other
Reasons:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Person fi ling this form (if different from above):
______________________________________________
Phone ( ______ ) _________ - ____________________
______________________________________________
Fax
( ______ ) _________ - ____________________
______________________________________________
E-mail
_______________________________________
I am dissatisfi ed with the statement of account or appraisal report provided to me by the Department of Revenue for the
following reasons:
(Please list factual reasoning for your dissatisfaction. Include the tax periods you are disputing.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
(If more space is needed, please attach additional pages to this form.)
Choose
I request a review of my statement of account or appraisal
I request an informal review meeting to
OR
One:
report using only the information I have submitted.
provide additional information.
On issues of employee-employer relationship and independent contractors, contact the Department of Labor and Industry.
Inheritance and Estate tax issues other than refund denials will be settled through District Court. For locally assessed
property valuation review requests, use Form AB-26.
FOR DEPARTMENT USE ONLY
As a result of this informal review, an adjustment
was
was not
made for the following reasons: ________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Reviewed By: _______________________________________________ Title / Role: ____________________________
The results of this informal review were sent to the customer on (Date): _______________________________________
If you are dissatisfi ed with this decision, you may request further review by fi ling a Form APLS102F with the Offi ce of
Dispute Resolution within 15 days of the date on the notice of the determination from the department.
Mail Form APLS101F to: Montana Department of Revenue, PO Box 7149, Helena, MT 59604-7149
576
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