Enlarge image
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
6500022105
(BA+) 10-22
OFFICIAL USE ONLY
REV-65
BOARD OF APPEALS BOARD OF APPEALS
PO BOX 281021
HARRISBURG PA 17128-1021 PETITION FORM
START SECTION I TAX INFORMATION
MM/DD/YYYY
Ü Tax Type Appealed (select one): Tax Period Begin Date
Personal Income Tax Corporation Tax Sales/Use Tax
Employer Withholding Inheritance Tax PTRR Other Tax Period End Date
Type of Petition: Refund Reassessment/Review
FOR REFUND PETITION ONLY:
If petition is in regard to sales tax, please list amount(s) below:
Cash Total Refund Requested PA Tax Refund Philadelphia Tax Refund Allegheny County Tax Refund
Credit
FOR REASSESSMENT/REVIEW PETITION ONLY: MM/DD/YYYY
Assessment Letter ID Assessment Letter Mail Date Tax Assessment Amount Penalty/Fees Assessment Amount
MM/DD/YYYY
Paid: Yes No If paid, date paid
Are there any current Yes Audit Number Are there any current Yes Docket Number
audits for this taxpayer appeals for this taxpayer
or tax period? No or tax period? No
SECTION II PETITIONER INFORMATION
Individual Corporation Partnership (attach list of partners & addresses) Other
MM/DD/YYYY
Estate Date of Death (required for estates &
personal income tax fiduciary appeals)
Legal Name (for individual applicants give your full legal name) SSN/FEIN Account ID
Trade Name or DBA (if different from Legal Name) Secondary ID (see instructions) Telephone Number
Contact Last Name Contact First Name Email Address
Address City State ZIP Code Country Code
SECTION III REPRESENTATIVE INFORMATION
Company Name Telephone Number
Contact Last Name Contact First Name Email Address
Address City State ZIP Code Country Code
6500022105 6500022105
PAGE 1
RESET FORM TOP OF PAGE NEXT PAGE PRINT
