Form Aa-1 - Appeal Application - 2016 Page 2
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Form AA-1
(2016)
Section 5
Statement of Facts
State the facts and the law or other legal authority, if any, to support your position on each disagreed item. If you
need more space, attach additional sheets.
Section 6
Signature of Petitioner(s)
Other Requirements: Please check off each box to indicate that you have
fulfilled these requirements. Do not submit your tax return, receipts,
Mail your application to:
or other types of evidence with this application.
Hawaii Department of Taxation
F I enclosed a copy of each Department of Taxation assessment that I dispute
Administrative Appeals Office
with this application.
830 Punchbowl Street, Room 221
Honolulu, HI 96813-5094
F I provided a copy of this application including any accompanying documents
to the Department of Taxation auditor or examiner assigned to my case.
I declare that the information in this application and any accompanying documents are true, correct, and complete to the
best of my knowledge and belief.
Signature of Petitioner(s)
Print name(s) and title(s)
Date
To Be Completed by the Administrative Appeals Office
Date application received
Was this application filed timely?
SOL date
Case Number
F Yes
F No
Form AA-1
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Parent category: Financial