DBA-10 (BA) 04-19 (FI)

                                                               BOARD OF APPEALS 
       BOARD OF APPEALS                            REQUEST FOR COMPROMISE
       PO BOX 281021 
       HARRISBURG PA  17128-1021

       SECTION I              PETITIONER & REPRESENTATIVE INFORMATION
START  Petitioner                                                                  Taxpayer ID
Ü
       Board of Appeals Docket Number, if available

       Petitioner Address                                                          City                    State  ZIP Code

       Petitioner’s representative and address, if applicable
       Representative

       Representative Address                                                      City                    State  ZIP Code

      VSECTION II             APPEAL INFORMATION
       Type of Appeal                                                             Tax Period(s)  Amount at Issue

       SECTION III            COMPROMISE INFORMATION
       State the offer in compromise and the reason(s) for requesting the compromise. Attach additional pages if necessary.   Compromise Amount
       Enclose copies of any documentation that supports the offer in compromise.

       Acknowledgment
       Petitioner acknowledges that if the aforementioned appeal is compromised, a compromise order will be issued and petitioner waives any right to: 
             •   appeal the compromise order; 
             •   claim any refund of money paid pursuant to the compromise order; 
             •   claim any refund of the self-reported tax; or 
             •   file any petition or appeal that raises the same issues for the tax period(s) and liability(ies) addressed in the compromise order.

       SECTION IV             SIGNATURES                                                                  MM/DD/YYYY
       Petitioner Signature                                                                                Date
                                                   Please sign after printing.
       Representative Signature (if applicable)                                                            Date
                                                   Please sign after printing.

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                                                                      Pennsylvania Department of Revenue 

                                                                                  Instructions for DBA-10 
DBA-10 IN (BA) 04-19                                                 Board of Appeals Request for Compromise

                  GENERAL INSTRUCTIONS                               • Example of doubt as to liability: You were audited by  
                                                                               the Department. When this happened, you suffered 
         •This form may only be submitted in conjunction with                  a disaster (such as books and records were 
          an appeal to the Board of Appeals, preferably along                  destroyed in a fire or other natural disaster). The 
          with the Board of Appeal petition form, or as soon as                Department disallowed all expenses and issued an 
          possible after the petition is filed.                                assessment.  You are unable to reconstruct your 
                                                                               books and records, but you can provide an 
         •Please type or print neatly in blue or black ink.                    explanation that supports reasonable doubt justifying 
         •The Compromise Request MUST clearly state the                        a reduction to a portion of your assessment. 
          amount at issue and the proposed compromise 
          amount. 
                                                                     WHAT WILL NOT BE COMPROMISED                                      
         •The Compromise Request must state the reason(s)  
          for requesting the compromise.                                      •Denials of property tax/rent rebate claims will not be  
                                                                               considered. 
         •Additional pages may be attached to the form, if  
          necessary.                                                          •Denials of charitable exemptions will not be  
                                                                               considered. 
         •All forms must be signed and dated by the Petitioner  
          AND the Representative (if applicable).                             •Revocation of sales tax licenses will not be  
                                                                               considered. 
            WHAT MAY BE COMPROMISED                                           •Appeals pursuant to the Gaming Control Act will not  
                                                                               be considered. 
         •A compromise request will only be considered when  
          the Petitioner (1) illustrates doubt regarding the                  •Any offer of “zero” or “none” will not be considered.  
          liability and/or (2) the compromise promotes effective 
                                                                              Any “hardship” compromise request (based on  
          tax administration.                                        •
                                                                               inability to pay) will not be considered by the Board 
         •Possible reasons for submitting a ‘doubt as to liability’            of Appeals. 
          offer in compromise include the following: the 
                                                                              If Petitioner has not filed all Pennsylvania tax returns,  
          Department made a mistake interpreting the tax law;        •
                                                                               a compromise request will not be considered. 
          the Department failed to consider the evidence 
          presented; and/or new evidence is available to                      •If a criminal prosecution is pending, a compromise  
          support a change to an assessment.                                   request will not be considered.

www.revenue.pa.gov                                                                                                       DBA-10    1
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