| sheet001 REV-39 BA ( 06-01-17) Rev SALES AND USE TAX APPEAL SCHEDULE PETITIONER: DOCKET NO: SECTION I ( REQUIRED) SECTION II ( REQUIRED) SECTION III ( REQUIRED) ( BOARD USE ONLY) SECTION IV ADDITIONAL INFORMATION ( AS APPLICABLE) ( 1) ( 2) ( 3) ( 4) ( 5) ( 6) ( 7) ( 8) ( 9) ( 10) ( 11) ( 12) ( 13) ( 14) ( 15) Refund Requested Amount BOARD OF APPEALS US E DOCUMENTATION HYPERLINKS ACCOUNTING INFORMATION Vendor Name Invoice No. Invoice Date Item Description ( as detailed on invoice) Total Invoice Amount Invoice Amt Before Sales Tax Invoice Sales Tax Pd. Amount Tax Type ( S or U) Tax Payment Method ( check, EFT) Date- Tax Paid ( S) / Tax Remitted ( U) mo/day/yr ( Also see Sec. IV) Use Tax Pd. Amount STATE PHILA. ALLEGH. Factual Basis for Refund Legal Basis/Authority ( if known) Additional Comments T/E STATE PHILA. ALLEGH. COMMENTS INVOICE HYPERLINK PROOF OF PAYMENT HYPERLINK ADD'L INFORMATION HYPERLINK LOCATION/ DIVISION COST CENTER GL ACCT # GL ACCT NAME PERIOD USE TAX ACCRUED - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ( Insert lines above as ap propriate. Do not alter columns A-Z. Add columns to Section IV only) - - - - - - - - - - Totals - - - - - - - - - - - - - - - - - - - * Copies of Invoices and/or receipts must be provided * Copies of cancelled checks, bank statements, receipt or other payment remittance confirmation and use tax accrual records must be provided Document checksum: | sheet001 REV-39 BA ( 06-01-17) Rev SALES AND USE TAX APPEAL SCHEDULE PETITIONER: DOCKET NO: SECTION I ( REQUIRED) SECTION II ( REQUIRED) SECTION III ( REQUIRED) ( BOARD USE ONLY) SECTION IV ADDITIONAL INFORMATION ( AS APPLICABLE) ( 1) ( 2) ( 3) ( 4) ( 5) ( 6) ( 7) ( 8) ( 9) ( 10) ( 11) ( 12) ( 13) ( 14) ( 15) Refund Requested Amount BOARD OF APPEALS US E DOCUMENTATION HYPERLINKS ACCOUNTING INFORMATION Vendor Name Invoice No. Invoice Date Item Description ( as detailed on invoice) Total Invoice Amount Invoice Amt Before Sales Tax Invoice Sales Tax Pd. Amount Tax Type ( S or U) Tax Payment Method ( check, EFT) Date- Tax Paid ( S) / Tax Remitted ( U) mo/day/yr ( Also see Sec. IV) Use Tax Pd. Amount STATE PHILA. ALLEGH. Factual Basis for Refund Legal Basis/Authority ( if known) Additional Comments T/E STATE PHILA. ALLEGH. COMMENTS INVOICE HYPERLINK PROOF OF PAYMENT HYPERLINK ADD'L INFORMATION HYPERLINK LOCATION/ DIVISION COST CENTER GL ACCT # GL ACCT NAME PERIOD USE TAX ACCRUED - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ( Insert lines above as ap propriate. Do not alter columns A-Z. Add columns to Section IV only) - - - - - - - - - - Totals - - - - - - - - - - - - - - - - - - - * Copies of Invoices and/or receipts must be provided * Copies of cancelled checks, bank statements, receipt or other payment remittance confirmation and use tax accrual records must be provided Document checksum: |