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                                                                                                                                   PRINT      CLEAR

     Web-Fill              NC-242
     5-20                  Objection and Request for Departmental Review

Individual’s First Name                      M.I. Individual’s Last Name                      Individual’s Social Security Number

Spouse’s First  Name (If joint return filed) M.I. Spouse’s  Last Name (If joint return filed) Spouse’s Social Security Number (If joint return filed)

Individual Phone Number 

Entity’s Legal Name                                                                           Entity’s Federal Employer ID Number

Entity’s Trade Name                                                                           Account Number/NCDOR ID

Entity Contact Person                                                                         Entity Contact Person Phone Number 

Street Address

City                                                                                          State                        Zip Code
                                                                                                                           
Reason for Objection and Request for Departmental Review                 (Provide the requested information about the notice(s) that you are
requesting the Department to review. Important: Attach a copy of the notice(s) of proposed assessment, proposed denial of refund, or proposed adjustment.)
     Notice Number                           Date of Notice              Tax Type             Period Beginning             Period Ending 
                                                             
Use the space below to state in detail your specific objections to the Notice of Proposed Assessment, Notice of Proposed Denial of Refund, or Notice 
of Proposed Adjustment.  (Attach additional pages if necessary.  Attach all supporting documentation to your request for Departmental review.)

Taxpayer Signature:                                          Title:                                                        Date:
Signature of
Taxpayer’s Representative:                                                                                                 Date:
                          If a taxpayer’s representative signs this form, a Power of Attorney must accompany this request.
If you object to a proposed assessment, proposed adjustment, or proposed denial of refund, you must request a Departmental review of the proposed 
action as the first step in the appeals process.  To request a review, complete this form and mail it, along with all supporting documentation, to 
the address shown below.  This form may be used for any State or local tax administered by the Department of Revenue.  The request for review 
must be filed with the Department within 45 days after the following: (1) the date the Notice of the Proposed Assessment, Proposed Denial of 
Refund, or Proposed Adjustment was mailed by the Department, or (2) the date the Notice of Proposed Assessment, Proposed Denial of Refund, 
or Proposed Adjustment was personally delivered by a Department employee.

  MAIL TO:  North Carolina Department of Revenue, Customer Interaction Center, P.O. Box 471, Raleigh, NC 27602-0471