Request for Administrative Appeal
GENERAL INSTRUCTIONS:
PLEASE READ:
DO
•
use this form if you disagree with the amount due on an Official Assessment and desire to appeal the assessment
to the Office of State Administrative Hearings.
DO
•
attach a copy of the Official Assessment as well as any supporting documents.
•
DO
enter the Letter ID listed on the Official Assessment in Section 2 of this form. This information will assist the
Department in processing your appeal.
DO
•
try to submit this form electronically by visiting the Department’s Georgia Tax Center at
https://gtc.dor.ga.gov
v
.
DO NOT
•
submit this form if you want to request an installment payment agreement, seek a penalty waiver, or submit
an offer in compromise. Go online to the Georgia Tax Center
(https://gtc.dor.ga.gov)
for these options.
LINE BY LINE INSTRUCTIONS:
Section 1 Letter ID
If you received a notice from the Department showing an amount due, enter the Letter ID listed on the notice.
Check the appropriate tax type and enter the related tax identification number.
Check the appropriate box for Responsible Party, if applicable.
Enter the tax periods from the Notice of Official Assessment.
Section 2 Taxpayer Contact Information
Enter your Name (First, Middle Initial, and Last Name).
Enter your Social Security Number.
Enter your Spouse’s Name (First, Middle Initial, and Last Name), if a joint liability exists.
Enter your Spouse’s Social Security Number, if a joint liability exists.
Enter your Business Name, if business is being assessed.
Enter Employer Identification Number, if business is being assessed.
Enter Taxpayer’s Address (number, street, and room or suite no., city, state, ZIP code).
Enter Daytime Telephone Number.
Enter Mailing Address (if different from above) (number, street, and room or suite no., city, state, ZIP code).
Section 3 Representative Information
If you are being represented by an attorney, complete this section.
Section 4 Reason for Appealing
Provide a detailed explanation of why the Department should grant your protest.
Section 5 Signatures
Taxpayer or Representative must sign form.