Fillable Form 04-775 - Request For Informal Conference

Form 04-775 - Request For Informal Conference - 1996

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(PLEASE PRINT OR TYPE)

NAME

EIN or SSN

FSN(S)

MAILING ADDRESS (STREET or PO BOX)

NAME OF CONTACT PERSON

CITY, STATE AND ZIP CODE

DAYTIME PHONE NUMBER OF CONTACT PERSON

DATE OF LETTER OF ASSESSMENT OR DENIAL OF REFUND (Attach Copy)

TAX TYPE

10.

TAX YEAR(S) OR PERIOD(S)

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

11.

is requested by:

Telephone

Correspondence [My arguments and evidence are included.]

In Person at Anchorage

12.

Notice of representation by another person on my behalf is hereby given and a power of attorney form is enclosed.

13. Explanation

14. Under penalty of perjury, 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. (An officer must sign for a corporation, partnership or trust.) If prepared by a person

other than the taxpayer, the declaration is based on all information of which the person has knowledge.

DATE