REV-65 (BA+) 04-17 FOR INTERNAL USE ONLY BOARD OF APPEALS PO BOX 281021 HARRISBURG PA 17128-1021 717-783-3664 BOARD OF APPEALS PETITION FORM TAX INFORMATION o Sales/Use Tax o Employer Withholding o Corporation Tax o Personal Income Tax o Other ________________ Account ID ________________ Is this a petition for refund? Federal Employer ID (FEIN) ________________ Revenue ID ________________ Tax Period: Begin ___________________________ End ______________________________ SECTION 1. o Yes o No If yes, o Cash o Credit Total Refund Requested $ _____________ Allegheny County Tax Refund $ ____________ If petition is in regard to sales tax, please list amount(s) below: Are there any current appeals or audits for this taxpayer or tax period? o Yes o No If yes, please provide relevant docket number _______________ assessment number _______________ and/or audit assignment number _________________ Is this a petition for reassessment/review of tax, penalty and/or interest? Penalty/Fees Assessment Amount $___________________ Paid PA Tax Refund $ ____________ Philadelphia Tax Refund $ ____________ o Yes o No Notice Number ______________________ Notice Mail Date ____________ Tax Assessment Amount $ ________________ o Yes o No If paid, date paid ____________ o Corporation o Estate Business Name Trade Name SECTION 2. o Individual o Partnership (Attach a list of partners and addresses.) o Other __________________ PETITIONER INFORMATION Date of Death _____________ (required for estates & personal income tax fiduciary appeals.) 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 __________________ Website _________________________________ Telephone _____________________ Fax ______________________ Email ________________________________ Contact Person ______________________________________________ Contact Phone Number _____________________ SECTION 3. 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 __________________ Website _________________________________ Telephone _____________________ Fax ______________________ Email ________________________________ Contact Person ______________________________________________ Contact Phone Number _____________________ FOR INTERNAL USE ONLY DOCKET # ______________________ EXAMINER _______________________ PETITION DUE ______________________ American LegalNet, Inc. www.FormsWorkFlow.com o Hearing requested. o No hearing requested. Please decide on basis of the petition and record. o This case to be held pending action on the same issue(s). SECTION 5. SECTION 4. SCHEDULING REQUEST Case Number __________________ Court Citation Number __________________ CORRESPONDENCE WITH THE BOARD OF APPEALS Communication, including the board's final decision and order, may be transmitted to you or your representative via email, should you elect so below. If you elect to receive communications via email, 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 email. Send correspondence to (select only one): Send correspondence via (select only one): Send Decision and Order via (select only one): SECTION 6. o Petitioner o U.S. Mail o U.S. Mail or or or o Representative o Email o Email ISSUES Itemize the issue(s) involved. What is the subject of appeal? SECTION 7. ARGUMENTS SECTION 8. COMPROMISE The Board of Appeals will consider compromises of assessment and refund appeals. If you wish to propose a compromise, please complete and submit a Request for Compromise (DBA-10) with your petition or within 30 days from the date the petition is filed. SECTION 9. SIGNATURES All petitions must be signed by the petitioner or authorized representative. 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 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 Representative's Name and Title Representative's Signature American LegalNet, Inc. www.FormsWorkFlow.com Date ________________________ Date ________________________ Pennsylvania Department of Revenue Instructions for REV-65 REV-65 IN (BA+) 04-17 Board of Appeals Petition Form Hearings, if requested, are held in Harrisburg. Petitioner may request a phone conference in lieu of a hearing. It is at the Board's discretion whether to grant this request. Sections 6 and 7: Issues and Arguments Briefly state the issue(s) involved. Please check desired method of correspondence. Please type or print neatly in blue or black ink. GENERAL INFORMATION Please attach a copy of the notice being appealed. Petitions should be sent directly to the Board of Appeals by mail, online or fax. Account ID Number is the number used to identify the tax account being appealed. Examples include the Sales Tax License Number, the Corporate Box Number, Estate File Number or Control Number. of Record such as revocation of a lottery license can be identified in Other. The preferred method of filing is online because this method provides a confirmation number. Online pet