FOR INTERNAL USE ONLY REV-65 BA (12-08) BOARD OF APPEALS PETITION FORM Board of Appeals PO BOX 281021 Harrisburg PA 17128-1021 GENERAL INSTRUCTIONS: Please type or print neatly in blue or black ink. Attach a copy of the notice being appealed. Mail this petition to the address above. Petitions filed via the U.S. Postal Service are considered filed as of the postmark date. The department does not recognize meter dates. Petitions filed by any other method are considered filed on the date received by the department. TAX INFORMATION: Sales Tax Employer Withholding Tax Corporation Tax Personal Income Tax Other _________________ Account ID # ______________________________ Federal Employer Identification # ______________________________ Tax Period: Begin ___________________________ End ______________________________ Is this a petition for refund? Yes No If yes, Cash Credit Total Amount of Refund Requested $ ___________ If petition is in regard to PA Sales Tax, please list proportion below: 6% State Refund $ ______________ 1% Philadelphia Refund $ ______________ 1% Allegheny Refund $______________ Has any portion of this request been included in another petition for refund or requested in a current or prior audit? Yes No If yes, please provide relevant docket # ________________ and/or assessment # ________________ Is this a petition for reassessment of tax, penalty and/or interest? Yes No Notice # _________________________ Notice Mailing Date ______________________ PETITIONER INFORMATION: Corporation Individual Partnership (attach a list of partners and addresses) Other __________________ Estate Date of Death __________________ (Date of Death Required for Estates & Personal Income Tax Fiduciary Appeals) Business Name Trade Name Individual Last Name _________________________________________ First Name _________________________ MI ___ Social Security Number _________________________ *PRIVACY NOTIFICATION: The department is authorized under federal law, 42 U.S.C. § 405 (c), to use your Social Security number in administering state tax law. The department uses your Social Security number to establish your identity and to process your appeal. Street Address ___________________________________________ City _____________________________ State _____ Country _______________________ ZIP Code +4 _________–_________ Web site _______________________________ Telephone # (____) _______________ Fax # (____) _______________ E-mail Address ___________________________ Contact Person ______________________________________________ Contact Phone Number (____) ________________ REPRESENTATIVE INFORMATION: Representation by an attorney, CPA or other person is not required. However, if so represented, complete this area. Business Name Individual Last Name _________________________________________ First Name _________________________ MI ___ Street Address ___________________________________________ City _____________________________ State _____ Country _______________________ ZIP Code +4 _________–_________ Web site _______________________________ Telephone # (____) _______________ Fax # (____) _______________ E-mail Address ___________________________ Contact Person ______________________________________________ Contact Phone Number (____) ________________ SCHEDULING REQUEST: Hearing requested. FOR INTERNAL USE ONLY DOCKET # No hearing requested. Please decide on basis of the petition and record. This case to be held pending action of court on the same issue(s). EXAMINER Case # _______________________ Court Citation # _______________________ PETITION DUE American LegalNet, Inc. www.FormsWorkflow.com CORRESPONDENCE WITH THE BOARD OF APPEALS: Communication, including the Board’s final decision and order, may be transmitted to you or your representative via e-mail by making the election below. Electronic communications via e-mail are unsecured. If you elect to receive communications via e-mail, 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 e-mail. Send correspondence to (select only one): Petitioner or Representative Send correspondence via (select only one): U.S. Mail or E-mail Send Decision and Order via (select only one): U.S. Mail or E-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 APPEAL SCHEDULE (REV-39), following the instructions on the reverse side of the form. Appeal schedules may be submitted on computer disk. 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 www.boardofappeals.state.pa.us. SIGNATURES: All petitions must be signed by the petitioner or authorized representative. The department requires an original signature; therefore, no faxed, photocopied or ink-stamped signatures will be accepted. 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 hereby 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 Date ________________________ Representative’s Name and Title Representative’s Signature Date ________________________ American LegalNet, Inc. www.FormsWorkflow.com