Excel document

sheet001

REV-39 BA (06-01-17) Rev

SALES AND USE TAX
APPEAL SCHEDULE

PETITIONER:

DOCKET NO:

SECTION I (REQUIRED)

SECTION II (REQUIRED)

SECTION III (REQUIRED)

(BOARD USE ONLY)

SECTION IV ADDITIONAL INFORMATION (AS APPLICABLE)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

(15)

Refund Requested Amount

BOARD OF APPEALS US

DOCUMENTATION HYPERLINKS

ACCOUNTING INFORMATION

Vendor Name

Invoice No.

Invoice Date

Item Description (as detailed on invoice)

Total Invoice Amount

Invoice Amt Before Sales Tax

Invoice Sales Tax Pd. Amount

Tax Type (S or U)

Tax Payment Method (check, EFT)

Date- Tax Paid (S) / Tax Remitted (U) mo/day/yr (Also see Sec. IV)

Use Tax Pd. Amount

STATE

PHILA.

ALLEGH.

Factual Basis for Refund

Legal Basis/Authority (if known)

Additional Comments

T/E

STATE

PHILA.

ALLEGH.

COMMENTS

INVOICE HYPERLINK

PROOF OF PAYMENT HYPERLINK

ADD'L INFORMATION HYPERLINK

LOCATION/ DIVISION

COST CENTER

GL ACCT #

GL ACCT NAME

PERIOD USE TAX ACCRUED

(Insert lines above as ap

Totals

* Copies of Invoices and/or receipts must be provided

* Copies of cancelled checks, bank statements, receipt or other payment remittance confirmation and use tax accrual records must be provided

Document checksum: 603246954

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