Form Dba-10 - Board Of Appeals - Request For Compromise
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1DBA-10 - (11-11)
BOARD OF APPEALS
REQUEST FOR COMPROMISE
General Instructions:
This form may only be submitted in conjunction with a petition to the Board of Appeals, either along with Board of
Appeals Petition Form REV-65 or as soon as possible after the petition is filed.
Please type or print clearly in blue or black ink.
Note that a compromise will only be considered when it illustrates doubt regarding liability and/or it promotes effective
tax administration.
Compromises addressing any of the following will not be considered:
•
Appeals of denials of property tax/rent rebate claims
•
Denials of charitable tax exemptions
•
Revocation of sales tax licenses
•
Appeals pursuant to the Gaming Control Act
SECTION 1: PETITIONER & REPRESENTATIVE INFORMATION
Petitioner:
Taxpayer ID:
Board of Appeals Docket Number, if available:
Petitioner Address:
City:
State:
ZIP Code:
Petitioner’s representative and address, if applicable
Representative:
Representative Address:
City:
State:
ZIP Code:
SECTION 2: APPEAL INFORMATION
Type of Appeal:
Tax Period(s):
Amount at Issue:
SECTION 3: COMPROMISE INFORMATION
State the offer in compromise and the reason(s) for requesting the compromise. Attach additional pages if necessary.
Enclose copies of any documentation that supports the offer in compromise.
Acknowledgement
Petitioner acknowledges that if the aforementioned appeal is compromised, a compromise order will be issued and peti-
tioner waives any right to:
•
appeal the compromise order;
•
claim any refund of money paid pursuant to the compromise order; or
•
file any petition or appeal that raises the same issues for the tax period(s) and liability(ies) addressed in the
compromise order.
Petitioner Signature:
Date:
Representative Signature (if applicable):
Date:
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