CDTFA-416 REV. 10 (1-18)                                                                                        STATE OF CALIFORNIA 
PETITION FOR REDETERMINATION                                   CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION 
BUSINESS NAME                                                                             ACCOUNT NUMBER 

TAXPAYER/FEEPAYER NAME                                                                    TYPE OF TAX OR FEE 

                                           PETITION FOR REDETERMINATION 
                                                     Administrative Appeal 
Generally, if you have received a notice of amount due from the California Department of Tax and Fee Administration (CDTFA), you may 
file an administrative appeal of that notice using this Petition for Redetermination. There are two important deadlines: 
1.        If you received aNotice of Determination, aNotice of Deficiency Assessment,   or aNotice of Successor Liability, you have
          30 days from the date on the notice to appeal.
2.        If you received a Jeopardy Notice of Determination, you only have 10 days from the date listed on that document to appeal
          and pay the amount due or deposit security considered acceptable by the CDTFA.
Look carefully at the notice you received for the specific conditions and requirements for filing this petition. Anyone submitting a petition 
should be prepared, upon request, to provide documents that support the specific grounds upon which the petition is founded. 
I am filing a petition of the notice dated                                    for the period 
in the amount of $                                          . 
Please indicate below the specific grounds upon which the petition is founded (required): 

          In addition, I have new documentation ready to present for review and consideration. 
You have the right to, and may request, an appeals conference. During the review of your petition, CDTFA staff may ask you about your 
request for an appeals conference, and confirm whether you still want an appeals conference. You must respond timely to that request. If 
your case is accepted into the administrative appeals process, you may request that your case be considered under the CDTFA’s 
administrative Settlement Program. Review under the Settlement Program is confidential and will not affect your appeal rights. 
Please indicate your requests below: 
          I request an appeals conference with an Appeals Bureau attorney or auditor at the CDTFA’s nearest office or in the 
          CDTFA’s Headquarters office in Sacramento. 

          I request my appeal be considered under the Settlement Program. 

SIGNATURE                                  DATE SIGNED                                     DAYTIME TELEPHONE NUMBER 

PRINTED NAME                               TITLE/CAPACITY                                  EMAIL ADDRESS 

If there is a conflict between this form or the notice you received and the law, the law is controlling. The filing of a Petition for Redetermination 
does not protect your right to a refund of tax/fee, interest, or penalty amounts paid in excess of amounts legally due. You must timely file a claim 
for refund if you believe you have overpaid tax/fee, interest, or penalty amounts. Filing a petition will not prevent interest from accruing on any 
unpaid tax/fee due. 

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