Abatement of Interest for Unreasonable Errors or Delays
                    Caused by the Arizona Department of Revenue

                    Do not use this form to request an adjustment to a 
                    current or recent billing.

This form should be used ONLY in those cases where a taxpayer’s 
fi nal bill has been affected by unreasonable errors or delays on 
the part of Arizona Department of Revenue audit or collections 
personnel.

For questions or concerns about a recent billing statement, 
contact our Taxpayer Information and Assistance Section at:

                    For Income and Corporate Tax Types: (602) 255-3381
                    Toll-free from within Arizona: (800) 352-4090

                    For TPT and Withholding Tax Types: (602) 255-2060
                    Toll-free from within Arizona: (800) 843-7196

The mailing address is:
                    PO Box 29086
                    Phoenix, AZ  85038-9086

ADOR 91-5384f (9/04)

                           Abatement of Interest for Unreasonable Errors or Delays
                           Caused by the Arizona Department of Revenue
                    This completed form or a letter containing the information below is required for consideration of an abatement request.

1.  TAXPAYER INFORMATION - Please print or type.                                                  Enter only those that apply:
   TAXPAYER NAME(S)                                                                               FEDERAL EMPLOYER IDENTIFICATION NUMBER

   PRESENT ADDRESS - NUMBER AND STREET, RURAL ROUTE, APARTMENT/SUITE NO.                          ARIZONA WITHHOLDING NUMBER

   CITY, TOWN OR POST OFFICE                                               STATE      ZIP CODE    ARIZONA TRANSACTION PRIVILEGE TAX LICENSE NUMBER

   DAYTIME TELEPHONE NUMBER (WITH AREA CODE)                                                      SOCIAL SECURITY NUMBER(S)

2. Abatement of interest is requested for the following tax year(s) or period(s):   

3.  Amount of interest requested to be abated:  $______________________.

4.  UNREASONABLE ERROR OR DELAY.
   a.  Please describe the nature and duration of the Departmental error or delay.  Be sure to include all relevant dates.  Attach supplemental pages if necessary.
   
   b.  Please indicate the section of the Department or employee/offi cer of the Department responsible for the error or delay:
   
   c.  Please indicate the cause of the error or delay:   
   
5.  SIGNATURE OF OR FOR TAXPAYER(S).  By signing this form, I certify that I have the authority to execute this abatement request form on behalf of the above-
   mentioned corporation(s), limited liability company(ies), trust(s), partnership(s), and/or individual(s).  I further certify that to the best of my knowledge the
   information provided in this form is true and accurate.

   ►                                                                                            ► 
    SIGNATURE                                             DATE                                    SIGNATURE                                DATE

     PRINT NAME                                                                                   PRINT NAME

     TITLE (if applicable)                                                                       TITLE (if applicable)
                    If you have been in contact with a Department of Revenue employee, fi le this request with that employee, or mail 
                    to Arizona Department of Revenue, Problem Resolution Offi cer, 1600 West Monroe, Phoenix, AZ, 85007-2650.

ADOR 91-5384f (9/04)