NC-242
Web                                       Objection and Request for Departmental Review
4-12                                                  North Carolina Department of Revenue
Individual’s First Name                    M.I.       Individual’s Last Name                                                     Individual’s Social Security Number

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

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

Entity’s Trade Name                                                                                                              Account ID

Street Address                                                                                                                   Contact Person if Questions

City                                                                         State              Zip Code                         Phone Number of Contact Person  (Include Area Code)

Part 1. Proposed Assessment (Attach a copy of the Notice of Proposed Assessment that you are requesting the Department to review.)
Use the space below to state in detail your specic objections to the Notice of Proposed Assessment.  (Attach additional pages if necessary.)

Provide the following information:

Tax Type                                Notice Number        Date of Notice                              Period Beginning                  Period Ending 

Part 2. Proposed Adjustment or Proposed Denial of Refund  (Attach a copy of the Notice of Proposed Adjustment or Notice of Proposed 
        Denial of Refund that you are requesting the Department to review.)
Use the space below to state in detail your specic objections to the Notice of Proposed Adjustment or Notice of Proposed Denial of Refund.
(Attach additional pages if necessary.)

Provide the following information:

Tax Type                                Date Claim was Filed Date Claim was Denied                       Period Beginning                  Period Ending 

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 rst step in the appeals process.  To request a review, complete this form and mail it 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 led with the Department within 
45 days after the following: (1) the date the notice of the proposed adjustment, proposed denial of refund, or proposed assessment was mailed 
by the Department, or (2) the date the notice of the proposed adjustment, proposed denial of refund, or proposed assessment was personally 
delivered by a Department employee.
  MAIL TO:  North Carolina Department of Revenue, Customer Service, P.O. Box 471, Raleigh, NC 27602-0471