Administrative Appeal Petition Form - York Area Earned Income Tax Bureau (Page 2 of 2) in pdf

Administrative Appeal Petition Form - York Area Earned Income Tax Bureau Page 2

Please specify the type of tax and the tax year or tax years involved in this administrative

appeal petition:

The tax type is: ____________________________________________________

The tax year is, or tax years are: _____________________________________

My appeal petition involves the following information or the enclosed

information: ______________________________________________________

__________________________________________________________________

Taxpayer’s full name (

: _____________________________________

please print)

Taxpayer’s social security number: ___________________________________

Taxpayer’s address: ________________________________________________

_________________________________________________

Daytime telephone number (optional): (_____)__________________________

Special requests: ___________________________________________________

I wish to have the following named person accompany me to the requested

administrative appeal hearing (

______________________________

please print):

AFFIDAVIT

I do hereby affirm that the facts and information contained in the above petition, and in all

the accompanying exhibits and addendums attached thereto and submitted therewith, and that all

verbal and written information imparted to the York Area Earned Income Tax Bureau in connection

with this appeal, is true and correct to the best of my knowledge, information and belief, and I further

understand that false statements are made subject to the penalties of 18 Pa. C.S.A. section 4904

relating to unsworn falsification to authorities.

_____________________________________

Signature of taxpayer

Date:_______________________

______________________________________

Signature and title of taxpayer representative

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version 11/10/98

Administrative Appeal Petition Form - York Area Earned Income Tax Bureau Page 2