Form Bfr-003 - Pennsylvania Board Of Finance & Revenue - Petition Form
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1
2Board of Finance & Revenue
Petition Form
1
BOARD OF APPEALS DOCKET NUMBER(S)
DOCKET NUMBER
2
PETITIONER
NAME OF PETITIONER
CONTACT PERSON
STREET ADDRESS
CITY
STATE
ZIP
TELEPHONE NUMBER
FAX NUMBER
EMAIL ADDRESS
3
REPRESENTATIVE
NAME OF REPRESENTATIVE / CONTACT PERSON
NAME OF ORGANIZATION / FIRM
STREET ADDRESS
CITY
STATE
ZIP
TELEPHONE NUMBER
FAX NUMBER
EMAIL ADDRESS
4
TAX TYPE AT ISSUE
TAX TYPE
TAX PERIOD START
TAX PERIOD END
TAXPAYER IDENTIFICATION NUMBER
ASSESSMENT NUMBER
TAX AMOUNT
e.g.(SSN, EIN, ACCT. #)
Review of Resettlement / Reassessment Petition
Review of Refund Petition
5
SCHEDULING
HEARING DESIRED.
NO HEARING DESIRED. Please decide on the basis of petition and submission(s).
REQUEST FOR COMPROMISE. See instructions.
THIS CASE IS REQUESTED TO BE HELD PENDING ACTION OF THE COURT ON THE SAME ISSUE(S).
CASE NAME
COURT CITATION
6
SIGNATURES
All petitions must be signed by Petitioner or an authorized representative.
AFFIDAVIT
Under penalties prescribed by law, I hereby affirm that this petition has been examined by me and to the best of my
knowledge, information and belief, is true and correct and is not made for the purpose of delay. Also, if this is a petition for
a cash refund, I further affirm that all taxes have been paid to the Commonwealth and there are no outstanding tax liabilities.
Please check one:
SIGNATURE
PETITIONER
AUTHORIZED REPRESENTATIVE
PRINT NAME
DATE
BFR-003 (01192015)
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