REV-556 EO (04-13)

                     TAXPAYER REQUEST
OFFICE OF TAXPAYERS' FOR ASSISTANCE
RIGHTS ADVOCATE
LOBBY STRAWBERRY SQ
HARRISBURG  PA  17128

Taxpayer Name (Last, First, and Middle Initial)

Business Name

Address

City                                                                                         State                       ZIP

Daytime Telephone Number (Primary)                           Telephone Number
(                )                                                             (                )

Tax Type                                                                    Tax Identification Number/Social Security Number

Nature of Problem

Additional Comments

Taxpayer Signature                                                                                  Date

                     INTERNAL USE ONLY
CUSTOMER I.D.#                                                      EMPLOYEE