Form Apls102f - Notice Of Referral To The Office Of Dispute Resolution
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1MONTANA
Clear Form
APLS102F
Rev 10 10
Notice of Referral to the Offi ce of Dispute Resolution
You may use this form to appeal the notice of determination made by the Department of Revenue’s Business and Income Taxes
Division. This division issues a notice of fi nal determination after receiving a request for informal review of a tax adjustment. You need
to fi le this form with the Offi ce of Dispute Resolution within 15 days of the date on the notice of the division’s fi nal determination.
For more information about the appeal process, visit the tax appeal process section at revenue.mt.gov. If you need additional help, call
us toll-free at 1-866-859-2254 (in Helena 444-6900) Monday through Friday, 8 a.m. to 5 p.m.
1. Taxpayer Information
Name of Taxpayer(s) or Contact Person
SSN
Address
FEIN
City
State
Zip Code
Spouse’s Name (if joint liability)
Spouse’s SSN
Telephone Number
Fax Number
Email Address
Tax Type(s)
For Tax Period(s)
Account ID
-
-
2. Authorization of Representative
If you would like to have another individual represent you during the informal review, please provide the basic information below
and attach a completed Power of Attorney form. You can fi nd the Power of Attorney form in the downloadable forms section at
revenue.mt.gov or call us toll-free at 1-866-859-2254 (444-6900 in Helena). Federal Form 2848 is also acceptable if the “Tax Matters”
section identifi es the Montana tax type, form number and years that the representative is authorized to discuss with the department.
Name of Representative
Telephone Number
3. Basis for Objection
As required by law, you need to provide a written explanation of the basis for your objection. Please attach a copy of your Request
for Informal Review (Form APLS101F) and/or a factual statement for each disputed issue in your written explanation. Use the space
below and additional sheets as necessary. Failure to provide an explanation of the basis for your objection may result in denial of your
request.
Date of the Business and Income Taxes Division’s Notice of Determination: _____________________
The following issues are the basis for objection:
Signature of Taxpayer or Authorized Representative
Title
Date
Spouse’s Signature (if joint liability)
Date
Please mail this form to Montana Department of Revenue, PO Box 7701, Helena, MT 59604-7701 or email to
soaobjections@mt.gov.
*05020101*
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