Form Rev-788 Ba - Corporate Officer Signature Form - Commonwealth Of Pennsylvania
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1REV-788 BA (11-03)
COMMONWEALTH OF PENNSYLVANIA
BOARD OF APPEALS
DEPARTMENT OF REVENUE
PENNSYLVANIA
DEPT. 281021
DEPARTMENT OF
evenue
HARRISBURG, PA 17128-1021
CORPORATE OFFICER SIGNATURE FORM
BOA DOCKET NUMBER (S)
PETITIONER NAME AND ADDRESS:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
TAX IDENTIFICATION NUMBER (PA BOX NUMBER):
TAX TYPE:
TAX PERIOD:
AUTHORIZED REPRESENTATIVE:
BUSINESS NAME:
ADDRESS:
CITY:
STATE:
ZIP:
REPRESENTATIVE CONTACT PERSON:
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
Under penalties prescribed by law, I hereby certify that the above referenced Petition(s) has been
examined by me and that to the best of my knowledge, information and belief, the facts contained in
the Petition(s) are true, correct and complete and the Petition is not made for the purposes of delay.
Name and Title of Corporate Officer
Signature
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