Petition For Waiver Of Penalty
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MAIL THIS COMPLETED FORM AND ANY
DEPARTMENTAL USE ONLY
SUPPORTING DOCUMENTATION TO:
TENNESSEE DEPARTMENT OF REVENUE
PETITION NUMBER_________________________
ANDREW JACKSON STATE OFFICE BLDG.
th
12
FLOOR
NASHVILLE, TENNESSEE 37242
or
E-MAIL THE FORM TO penalty.waivers@tn.gov
PETITION FOR WAIVER OF PENALTY
Taxpayer Name
FEIN or Account Number
Taxpayer Representative (if applicable)
Who Should Be the Department’s Primary Contact?
Taxpayer
Taxpayer Representative (Include POA)
Address of Primary Contact
City, State, Zip of Primary Contact
Tax Type
Period Covered
Amount of Penalty
Date the Tax Was Paid
Note: Tax must be paid before penalty waiver will be considered.
Explain the reasons for the delinquent or deficient payment of the tax.
Explain the reason the penalty should be waived.
Does the taxpayer have a good filing history for at least the prior two years with the Department of Revenue?
Yes
No
By signing below, the taxpayer attests that the penalty did not result from gross negligence or willful disregard of the law.
Signature of Taxpayer or Taxpayer Representative:__________________________________Title:___________________Date_____________
Print Name Here: __________________________________________Email: _____________________________Phone No.:________________
RV-F1322701
(Internet 07-16)
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Parent category: Financial