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TSD-2
Form
(Rev. 12/11)
Georgia Department of Revenue
Request for Administrative Appeal
SECTION 1
Assessment Information
L
Enter Letter ID number listed on the Notice of Official Assessment (if available):
Check tax type and enter the related tax identification number and tax periods at issue:
FEIN:
SSN:
Individual Income Tax
-
Corporate Income Tax
-
-
STN:
IFTA: GA
Sales and Use Tax
IFTA Fuel Tax
WTN:
TAX ID:
-
Other
Withholding Tax
Check if you are are being assessed as a
responsible person for sales or withholding taxes or as a
successor to a business.
Enter tax periods listed on Notice of Official Assessment:
SECTION 2
Taxpayer Contact Information
Taxpayer’s First Name
Middle Initial
Last Name
Social Security Number
Spouse’s First Name (if a joint liability)
Middle Initial
Last Name
Social Security Number
Business Name
(use if business is being assessed)
Employer Identification Number
Taxpayer’s Address
Daytime Telephone Number
City
State
ZIP
Mailing Address
City
State
ZIP
SECTION 3
Representative Information
Complete this section only if you are being represented by an attorney. A Power of Attorney (Form RD-1061) authorizing the representa-
tive to act for the taxpayer must be included with this form.
Attorney’s Name
Telephone Number
Fax Number
Mailing Address
City
State
ZIP
ssment
SECTION 4
Reason for Appealing Official Assessment
Please provide a summary statement of the legal issues and factual matters to be resolved at the hearing. Attach additional pages, if
needed, and enclose copies of any supporting documents.