Department of Taxation and Finance Bureau of Conciliation and Mediation Services Request for Conciliation Conference Name of taxpayer Current address (number and street) City State ZIP code Daytime telephone number Taxpayer ID number (EIN or SSN) ( ) If you are not representing yourself, you must submit a properly completed power of attorney (Form POA-1) with this request. (For all estate tax matters, submit Form ET-14, Estate Tax Power of Attorney, instead of Form POA-1.) A Form POA-1 is not necessary if the person representing you is a spouse, parent, child, or guardian. See 20 NYCRR 4000.2. Taxpayer's representative, if any (name of representative and firm) Address (number and street) City State ZIP code Daytime telephone number ( ) I am requesting a conciliation conference for tax type: for the years and/or periods I am filing this request in response to receiving the following (enclose copy): Notice of deficiency, determination, or demand (attach additional sheets, if necessary) Notice dated Notice number L . Notice of disallowance, refund denial, or unanswered refund claim Notice dated Refund claim amount $ Refusal, revocation, suspension, or denial of a license, permit, certificate, registration or exempt status Notice type Dated Refund claim filed on / / I would like my conference scheduled at the Tax Department office located in: Albany Kew Gardens Binghamton Rochester Brooklyn Syracuse Buffalo White Plains Hauppauge Utica Explain why you disagree with the department notice (attach additional pages, if necessary): I understand that a willfully false representation is a misdemeanor punishable under section 210.45 of the Penal Law. Print name of person signing Signature Date Fax to: (518) 435-8554 CMS-1-MN (12/15) Page 1 of 2 or Mail to: NYS TAX DEPARTMENT BCMS W A HARRIMAN CAMPUS ALBANY NY 12227-0918 American LegalNet, Inc. www.FormsWorkFlow.com Notice of Taxpayer Rights If you disagree with an action taken by the Department of Taxation and Finance (the issuance of a tax deficiency/determination, the denial of a refund claim or the denial or revocation of a license, registration or exemption certificate), you may protest by filing a Request for Conciliation Conference or by filing a Petition for a Tax Appeals Hearing. The request or petition must be filed within a certain period from the date the department mailed you notice of its action. Please refer to the notice you received to determine your time limit. These time limits are established by the Tax Law and cannot be extended. We recommend you use certified or registered mail. See Publication 55, Designated Private Delivery Services, for a list of private delivery services that can also be used, and the address. You may appear on your own behalf or you may have an authorized representative present your case for review. An authorized representative must have a power of attorney from you to appear on your behalf. If you are a person with a disability and you wish to request that a reasonable accommodation be provided to you in order to participate in a conciliation conference, please call the Department's Diversity and Affirmative Action Office at (518) 530-4650 and they will assist you. Tax Appeals Hearing The procedure in the Division of Tax Appeals is begun by filing a petition. The petition must be in writing and must specifically indicate the actions of the department that are being protested. The hearing is an adversarial proceeding before an impartial administrative law judge. The hearing will be stenographically reported. After the hearing, the administrative law judge will issue a determination that will finally decide the matter(s) in dispute unless either you or the department requests review by the Tax Appeals Tribunal. If such a review is requested, the record of hearing and any additional oral or written arguments will be reviewed and the Tribunal will issue a decision affirming, reversing or modifying the administrative law judge's determination, or referring the matter back to the administrative law judge for further hearing. Court Review If you do not agree with the Tax Appeals Tribunal's decision, you may seek court review. There are time limits within which an application for court review must be filed. For some taxes, you must pay the tax, interest and penalty or post a bond for this amount, plus court costs, when you file an application for court review. Conciliation Conference Small Claims Option A Conciliation Conference is a rapid and inexpensive way to resolve protests without a formal hearing. The conference is conducted informally by a conciliation conferee who will review all of the evidence presented to determine a fair result. After the conference, the conferee will send you a proposed resolution in the form of a Consent. If you indicate your acceptance by signing and returning the Consent within 15 days, the disagreement will be concluded. Otherwise, the conferee will issue a Conciliation Order. This order is binding on the department and will be binding on you unless you file a petition for a hearing with the Division of Tax Appeals. To request a conference, complete page 1 of this form and fax to (518) 435-8554 or mail to the address on page 1. Note: Failure of technology or electronic communication or unavailability of the facsimile will not release the requestor from timely filing as required by the Tax Law. Privacy notification The right of the Commissioner of Taxation and Finance and the Department of Taxation and Finance to collect and maintain personal information, including mandatory disclosure of social security numbers in the manner required by tax regulations, instructions, and forms, is found in the New York State Tax Law, including subdivision 3-a of section 170 thereof; and 42 USC 405(c)(2)(C)(i). The Tax Department uses this information primarily to administer proceedings in the Bureau of Conciliation and Mediation Services, to identify the taxpayer, and for any other purpose authorized by law. Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law. This information is maintained by the Director of the Bureau of Conciliation and Mediation Services, NYS Tax Department, W A Harriman Campus, Albany NY 12227-0918; telephone (518) 530-4628. When petitioning for a hearing, you may elect to have your hearing held in the Small Claims Unit if the amount in dispute is within the dollar limits set by the Rules of Practi