Fillable Rev-65 - Board Of Appeals Petition Form (Page 2 of 2) in pdf

CORRESPONDENCE WITH THE BOARD OF APPEALS:

Communication, including the board’s final decision and order, may be transmitted to you or your representative via email,

should you elect so below. If you elect to receive communications via email, you and your representatives assume the

responsibility for the confidentiality of the information contained in emails sent to and from the Board of Appeals. The

commonwealth will not be held liable for the disclosure of any confidential information sent via email.

Send correspondence to (select only one):

Petitioner

Representative

Send correspondence via (select only one):

U.S. Mail

Send Decision and Order via (select only one):

U.S. Mail

ISSUES:

Itemize the issue(s) involved. What is the subject of appeal?

ARGUMENTS:

Explain in detail why relief should be granted. Attach additional pages if necessary. Enclose copies of any supporting

documents. Petitions for refund must be accompanied by proof of payment of the tax to the commonwealth and copies

of invoices, credit memoranda, exemption certificates, etc. where relevant. Copies of canceled checks must include

images of the fronts and backs of the checks. When submitting sales and use tax appeals (audit reassessments or refunds),

complete and attach an Appeal Schedule (REV-39), following the instructions on the reverse side of the form. Appeal

Schedules may be submitted electronically. A spreadsheet may also be created, using REV-39 as a guide. For information

and instructions, call 717-783-3664. The petition form and schedule are available on the Board’s Online Petition Center at

COMPROMISE:

The Board of Appeals will consider compromises of assessment and refund appeals. If you wish to propose a compromise,

please complete and submit a Request for Compromise (DBA-10) with your petition or at any time prior to issuance of a

final decision regarding the appeal.

SIGNATURES:

All petitions must be signed by the petitioner or authorized representative. If signed only by an authorized representative,

written authorization must accompany the petition. If the petitioner is a corporation, a corporate officer must sign.

Under penalties prescribed by law, I hereby certify this petition has been examined by me, and to the best of my knowledge,

information and belief, the facts contained in the petition are true, correct and complete and the petition is not made for

the purpose of delay. Also, if this is a petition for refund, I certify that the refund requested has not been granted in an

audit report, nor has it been included in any other petition for refund.

Petitioner’s Name and Title

Petitioner’s Signature

Petitioner Please sign after printing

Date ________________________

MM/DD/YY

Representative’s Name and Title

Representative’s Signature

Representative Please sign after printing

Date ________________________

MM/DD/YY

RETURN TO PAGE ONE

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Rev-65 - Board Of Appeals Petition Form Page 2

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