Rev-65 - Board Of Appeals Petition Form

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FOR INTERNAL USE ONLY
REV-65 BA (03-13)
BOARD OF APPEALS
PETITION FORM
Board of Appeals
PO BOX 281021
Harrisburg PA 17128-1021
GENERAL INSTRUCTIONS:
Please type or print neatly in blue or black ink. Attach a copy of the notice being appealed.
Mail this petition to the address above. Petitions filed via the U.S. Postal Service are considered filed as of the postmark date.
The department does not recognize meter dates. Petitions filed by any other method are considered filed on the date received
by the department. Petitions may also be faxed to 717-346-2011.
TAX INFORMATION:
START
o
o
o
o
o
Sales Tax
Employer Withholding Tax
Corporation Tax
Personal Income Tax
Other _________________
Account ID Number _________________________ Federal Employer Identification Number _________________________
Tax Period: Begin ___________________________ End ______________________________
o
o
o
o
Is this a petition for refund?
Yes
No If yes,
Cash
Credit
Total Refund Requested $ ______________
If petition is in regard to sales tax, please list amount(s) below:
PA Tax Refund $ ____________
Philadelphia Tax Refund $ ____________
Allegheny County Tax Refund $____________
Has any portion of this request been included in another petition for refund or requested in a current or prior audit?
o
o
Yes
No If yes, please provide relevant docket number _____________ and/or assessment number _____________.
o
o
Is this a petition for reassessment/review of tax, penalty and/or interest?
Yes
No
Notice Number ______________________ Notice Mailing Date ____________ Assessment Amount $ _________________
PETITIONER INFORMATION:
MM/DD/YY
o
o
o
o
Corporation
Individual
Partnership (Attach a list of partners and addresses.)
Other __________________
o
Estate
Date of Death _____________ (Date of Death required for estates & personal income tax fiduciary appeals.)
MM/DD/YY
Business Name
Trade Name
Individual Last Name _________________________________________ First Name _________________________ MI ___
Social Security Number _________________________ PRIVACY NOTIFICATION: The department is authorized under
federal law, 42 U.S.C. § 405 (c), to use your Social Security number in administering state tax law. The department uses your
Social Security number to establish your identity and to process your appeal.
Street Address ___________________________________________ City ______________________________ State _____
Country _______________________ ZIP Code +4 ___________________ Website ________________________________
Telephone _____________________ Fax ______________________ Email Address _______________________________
Contact Person ______________________________________________ Contact Phone Number ______________________
REPRESENTATIVE INFORMATION:
Representation by an attorney, CPA or other person is not required. However, if so represented, complete this area.
Business Name
Individual Last Name _________________________________________ First Name _________________________ MI ___
Street Address ___________________________________________ City ______________________________ State _____
Country _______________________ ZIP Code +4 ___________________ Website ________________________________
Telephone _____________________ Fax ______________________ Email Address _______________________________
Contact Person ______________________________________________ Contact Phone Number ______________________
SCHEDULING REQUEST:
FOR INTERNAL USE ONLY
o
Hearing requested.
DOCKET #
o
No hearing requested. Please decide on basis of the petition and record.
EXAMINER
o
This case to be held pending action of court on the same issue(s).
PETITION DUE
Case Number __________________ Court Citation Number __________________
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