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                                        (BA+) 01-20
                                                                                                                OFFICIAL USE ONLY
                        REV-65 
                        BOARD OF APPEALS                 BOARD OF APPEALS 
                        PO BOX 281021 
                        HARRISBURG PA 17128-1021PETITION FORM

START SECTION ITAX INFORMATION
Ü     Tax Type Appealed (select one):                                                                   Tax Period Begin Date        MM/DD/YYYY
          Personal Income Corporation TTax               Employer Withholdingax
                                                                                                        Tax Period End Date          MM/DD/YYYY
          Sales/Use Tax               Other

      Type of Petition:RefundReassessment/Review

      FOR REFUND PETITION ONLY:
          Cash CreditTotal Refund Requested $

      If petition is in regard to sales tax, please list amount(s) below:
      PA Tax Refund                          Philadelphia Tax Refund Allegheny County Tax Refund

      FOR REASSESSMENT/REVIEW PETITION ONLY:
      Notice Number                          Notice Mail Date                  MM/DD/YYYY               Tax Assessment Amount

      Penalty/Fees Assessment Amount                                                                                                           MM/DD/YYYY
                                             Paid:       Yes                   NoIf paid, date paid

      Are there any current appeals or audits for this taxpayer or tax period?Yes            No
      Docket Number                          Assessment Number                                          Audit Assignment Number

      SECTION IIPETITIONER INFORMATION
          Individual            Corporation Partnership (attach list of partners & addresses)Other
          EstateDate of Death   MM/DD/YYYY                                     (required for estates & personal income tax fiduciary appeals)

      Legal Name (for individual applicants give your full legal name)SSN                                                  Account ID

      Trade Name or DBA (if different from Legal Name)FEIN                                                                 Revenue ID

      Mailing Address

      City                                  StateZIP CodeCountry

      Contact Person Name                   Contact Email Address                                                          Contact Telephone Number

      SECTION IIIREPRESENTATIVE INFORMATION
      Company Name                                                             Contact Person                              Contact Person Title

      Address                                                                  City                                        StateZIP Code

      Country                               Email Address                                                                  Telephone Number

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REV-65 (BA+) 01-20

SECTION IVSCHEDULING REQUEST
Hearing RequestedNo Hearing Requested. Please decide on basis of the petition and record.
This case to be held pending action on the same issue(s). Case Number Court Citation Number

SECTION VCORRESPONDENCE WITH THE BOARD OF APPEALS
If you elect to receive communications via email, you are authorizing the Board of Appeals to send correspondence, including the final Decision & Order,
via email.
Send Correspondence to (select one):PetitionerRepresentative
Send Correspondence via (select one):U.S. MailEmail
Send Decision and Order via (select one):U.S. MailEmail

SECTION VIISSUES & ARGUMENTS
Itemize the issue(s) involved. What is the subject of appeal? Attach a separate sheet if more space is required.

SECTION VIICERTIFICATION
ALL APPLICANTS MUST COMPLETE THIS SECTION
All petitions must be signed by the petitioner or authorized representative. If signed only by an authorized representative, written authorization must
accompany the petition. If the petitioner is a corporation, a corporate officer must sign.
Under penalties prescribed by law, I hereby certify this petition has been examined by me, and to the best of my knowledge, information and belief, the
facts contained in the petition are true, correct and complete and the petition is not made for the purpose of delay. Also, if this is a petition for refund, I
certify that the refund requested has not been granted in an audit report, nor has it been included in any other petition for refund.
MM/DD/YYYY
Petitioner’s Name Petitioner’s Signature Petitioner’s Title Date
PLEASE SIGN AFTER PRINTING
Representative’s Name Representative’s SignatureRepresentative’s TitleDate
PLEASE SIGN AFTER PRINTING

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Instructions for REV-65
REV-65 IN (BA+) 01-20 Board of Appeals Petition Form

CURRENT APPEALS AND AUDITS
GENERAL INFORMATION
If there are any current appeals or audit for this taxpayer or
Please type or print neatly in blue or black ink. Attach a copy tax period, provide docket number, assessment number
of the notice being appealed. and/or audit assignment number. This section is applicable
to petitions for refund and petitions for reassessment/review.
Petitions should be sent directly to the Board of Appeals
online or by mail. The preferred method of filing is online SECTION II
because this method provides a confirmation number.
Online petitions are filed through the Board of Appeals PETITIONER INFORMATION
website at www.boardofappeals.state.pa.us. The mailing SSN
address for the Board of Appeals is: Social Security number is required for Individual, Estate and
BOARD OF APPEALS Partnership appeals. Include Social Security number for
PO BOX 281021 each partner when providing list of partner names and
HARRISBURG PA 17128-1021 addresses.
Petition is considered filed as of the postmark date. Meter NOTE: The department is authorized under federal
dates or any other mark (except the USPS postmark) is not law, 42 U.S.C. § 405 (c), to use your Social Security
recognized. Failure to include any required information may number in administering state tax law. The department uses
result in a dismissal of your appeal. your Social Security number to establish your identity and
to process your appeal.
COMPROMISE
The Board of Appeals will consider compromises of ACCOUNT ID
assessment and refund appeals. If you wish to propose a Account ID Number is the number used to identify the tax
compromise, please complete and submit a Request for account being appealed. Examples include the Sales Tax
Compromise (DBA-10) with your petition or within 30 days License Number, the Corporate Box Number, Estate File
from the date the petition is filed. Number or Control Number.
FEIN
SPECIFIC INSTRUCTIONS Federal Employer Identification Number is issued by the IRS

SECTION I to business entities. Complete this number if one has been
assigned to you.
TAX INFORMATION REVENUE ID
TAX TYPE APPEALED Departmental issued number assigned to each business
Fill in the oval for the tax type being appealed. Administrative entity with a filing requirement in PA.
Appeals of Record such as revocation of a lottery license
can be identified in Other. SECTION III

TAX PERIOD BEGIN AND END DATES REPRESENTATIVE INFORMATION
Please clearly identify the tax period being appealed. Representation by an attorney, CPA or other person is not
TYPE OF PETITION required. Complete representative information only if
Petitioner is represented by another person.
Fill in only one oval for the type of petition. Do not mark both.
PETITION FOR REFUND SECTION IV

Provide refund form and amount requested. If the refund
requested is for sales tax, provide requested amounts for SCHEDULING REQUEST
PA tax refund. If applicable, provide amounts for Hearings, if requested, are held in Harrisburg. Petitioner may
Philadelphia tax refund or Allegheny County tax refund. request a phone conference in lieu of a hearing. It is at the
Board’s discretion whether to grant this request.
PETITION FOR REASSESSMENT/REVIEW
Provide notice number, notice mail date, tax assessment SECTION V
amount, and penalty/fees assessment amount. If the tax
assessment amount and penalty/fees assessment amount CORRESPONDENCE WITH BOARD OF APPEALS
have been paid in full, provide date paid. Please select desired method of correspondence.

www.revenue.pa.gov REV-651

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NOTE: Communication, including the board’s final Any required appeal schedule should be submitted with the
decision and order, may be transmitted to you or your petition or within 30 days of the date that the petition is filed.
representative via email, should you elect the email option. Any evidence in support of the petition may be submitted
If you elect to receive communications via email, you and with the petition but no later than 60 days from the date that
your representatives assume the responsibility for the the petition is filed.
confidentiality of the information contained in emails sent to
and from the Board of Appeals. The commonwealth will not SECTION VII
be held liable for the disclosure of any confidential
information sent via email. CERTIFICATION
All petitions must be signed by the Petitioner and/or
SECTION VI Authorized Representative. A Power of Attorney (REV-677)
must be submitted if the petition is only signed by the
ISSUES AND ARGUMENTS authorized representative.
Briefly state the issue(s) involved and explain in detail why
relief should be granted. Additional pages may be attached,
if necessary.

2 REV-65 www.revenue.pa.gov

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