FOR OFFICE USE ONLY
     The City of New York

                                                               PETITION

   NEW YORK CITY TAX APPEALS TRIBUNAL
   ADMINISTRATIVE LAW JUDGE DIVISION                                                                                EMPLOYER IDENTIFICATION NUMBER OR 
                                                                                                                    SOCIAL SECURITY NUMBER  ▼
--------------------------------------------------------------X
     In the Matter of the Petition of                                                        :                      _____________________________________________
                                                                                             :                      DEPARTMENT OF FINANCE AUDIT/CASE NUMBER  ▼
                                                                                             :
                                                                                                                    _____________________________________________
                                                                                             :
                                                                                             :                      TYPE OF TAX / CHARGE: ____________________________________
                                                                                             :
                                                                                                                    TAX PERIOD(S) / DATE(S) 
__________________________________:                                                                                 OF TRANSACTION(S): _______________________________________
        (NAME OF TAXPAYER / PETITIONER)
--------------------------------------------------------X
Petitioner’s address:  ______________________________________________________________________________
                               ______________________________________________________________________________
Telephone number:              ( ______ ) _________________________   Fax number: ( ______ ) ________________________

Representative’s name: ____________________________________________________________________________
     A duly executed Power of Attorney authorizing the representative's appearance in this matter before the Tax Appeals Tribunal must be attached.

Representative’s firm and address:   __________________________________________________________________ 
     _________________________________________________________________________________________
Telephone number:              ( ______ ) _________________________   Fax number: ( ______ ) ________________________

Representative’s capacity:   ❐ Attorney       ❐ C.P.A.       ❐ P.A.       ❐                  Enrolled Agent       ❐ Corporate Employee       ❐ Other: _____________________

1. PETITIONER HEREBY REQUESTS THE FOLLOWING RELIEF:

   ❑ Redetermination of a deficiency                                                                                                A legible copy of the Notice of
     Date of Notice of Determination ...............................                         _______/_______/_______                Determination must be attached.
     Principal tax due per Notice               ........................................ $______________________
     Interest due per Notice   ................................................... $______________________                 Has a jeopardy assessment been issued?
     Penalty due per Notice    ................................................... $______________________                                            YES                    ❐ NO
                                                                                                                                               ❐ 
     Total due per Notice      ......................................................... $______________________
        OR
   ❑ Allowance of refund/credit
     Date of Notice of Disallowance             ................................             _______/_______/_______       A legible copy of the Notice of Disallowance
                                                                                                                           or, if none has been issued within 6 months
     OR                                                                                                                    of the filing of a GCT, UBT or BCT refund
     Date of Claim for Refund                 .............................................. _______/_______/_______       claim, the claim for refund must be attached.
     Refund requested          ............................................................. $ _____________________
        OR
   ❑ Other relief (identify) : __________________________________                A legible copy of the Notice must
                                                                                                                                                      be attached.
     Date of protested Notice     ............................ _______/_______/_______ 

2. SMALL CLAIMS ELECTION:
   The informal small-claims procedure resolves the controversy through a Determination issued by a Presiding Officer of the
   Tribunal which is binding on both parties and is not subject to review at the Appeals Division of the Tribunal or in the courts.
   If the matter at issue is not more than $10,000, exclusive of interest and penalty, 
   does Petitioner request that the proceeding be conducted in the small claims unit?                                      ............................................... ❑ YES ❑ NO

3. CONCILIATION CONFERENCE:
   Please note that you may not simultaneously request a conciliation conference and a hearing before the Tribunal.  If a conciliation con-
   ference was requested but a conciliation decision has not yet been issued, you may not request a hearing before the Tribunal until after
   the conciliation decision has been issued.
   ❑ A conciliation conference in the Department of Finance’s Bureau of Conciliation was not requested.
   ❑ A conciliation conference in the Department of Finance’s Bureau of Conciliation was requested and a conciliation decision
     was issued on ______/______/______.
   Legible copies of the conciliation decision and the protested Notice of Determination or Notice of Disallowance must be attached.

4. PETITIONER ALLEGES THAT THE COMMISSIONER OF FINANCE MADE THE FOLLOWING ERROR(S) OF FACT
   OR LAW AND STATES THAT THE FACTS AND LAW UPON WHICH PETITIONER RELIES ARE AS FOLLOWS: 
     This section must be filled out.  Use separately numbered paragraphs.  Attach a separate sheet, if necessary.

WHEREFORE, Petitioner respectfully requests that this petition be granted.  The undersigned certifies that the
statements herein are made with the knowledge that a willfully false representation is a misdemeanor punish-
able under section 210.45 of the Penal Law of the State of New York.

     ____________________________________              ___________________________________             _____________
     Signature of Petitioner / Representative ▲        Title (if applicable)▲                          Date ▲

   If signed by a person other than the Petitioner, indicate capacity:
   ❑ General Partner        ❑  Officer       ❑  Representative        ❑ Other: ___________________________________________

                  WITHIN THE TIME LIMITATIONS PRESCRIBED BY APPLICABLE STATUTE, YOU MUST BOTH:

FILE THIS PETITION AND 2 CONFORMED COPIES WITH:                       AND SERVE 1 CONFORMED COPY OF THE PETITION ON:
Chief Administrative Law Judge                                        Corporation Counsel of the City of New York
NYC Tax Appeals Tribunal                                              Tax & Bankruptcy Division
Administrative Law Judge Division                                     100 Church Street, 4th Floor
The Municipal Building                                                New York, NY  10007
One Centre Street, Suite 2450
New York, NY  10007

The Corporation Counsel was served by: ❑       Mail ❑  Hand Delivery        ❑  Other: ___________________________

If filing and/or service is by mail, it should be made by certified or registered mail, return receipt requested.  An affidavit or other proof
of service should be enclosed with the Petition.  Please call (212) 669-4501 if you have any questions regarding this form.