TA-100 (06/17) 
 
                                     New York State Division of Tax Appeals 
                                     Agency Building 1, Empire State Plaza, Albany, NY 12223 
                                                                                                                                                            For Office Use Only 
                                                       Petition 
 
Purpose:  This form is to be completed by a petitioner (taxpayer) who wishes to have Tax 
Appeals review and resolve a New York State tax or licensing dispute with the Division of 
Taxation of the Department of Taxation and Finance.  This form is to be filed only in response to 
a written notice issued by the Division of Taxation advising the taxpayer of a tax deficiency, 
determination of tax due, denial of a refund or credit application; denial, cancellation, revocation 
or suspension of a license, permit or registration; or any other notice that gives that person the 
right to a hearing at Tax Appeals. 
 
Section I      Caption 
Enter name of the petitioner, tax article and tax period(s) to be challenged.  This information can be found on the notice being 
challenged. 
                                      In the Matter of the Petition 
                                                              of 
 
Name of Petitioner(s)  _______________________________________________________________________________________ 
 
For Redetermination of a Deficiency/Revision of Determination or for Refund under Article(s)   ______________________________ 
 
of the Tax Law for the Year(s)/Period(s)  ________________________________________________________________________ 
 
Section II     Petitioner Information 
Enter petitioner and contact information, including petitioner’s taxpayer ID number (e.g., social security number, employer identification 
number or a number assigned to the taxpayer by the Commissioner of Taxation and Finance).  This information will be used for tax 
administration purposes only. 
Name of Petitioner(s)                                  Taxpayer ID                                 Email Address 

Address                                                                  City                                              State                   Zip Code Telephone Number 

Section III    Petitioner’s Representative Information and Qualifications – see 20 NYCRR 3000.2 
Enter name and contact information of petitioner’s representative.  Also provide the representative’s qualifications.  Pursuant to 20 
NYCRR 3000.2, only certain representatives qualify to represent a petitioner.  A fully executed Power of Attorney form must accompany 
this petition if this section is completed.  Representatives indicating “other” may also be required to obtain special permission to appear 
before Tax Appeals and represent petitioner(s).  See 20 NYCRR 3000.2 (a) (4). 
Petitioner’s Representative, if any                                                                Email Address 

Address                                                                  City                                              State                   Zip Code Telephone Number 

Petitioner’s representative is:                                
                                                                    
 an attorney-at-law licensed to practice in New York State     an enrolled agent enrolled to practice before the Internal 
                                                                   Revenue Service 
                                                                  
 a certified public accountant duly qualified to practice in     an employee, not a corporate officer (if the taxpayer is a 
  New York State                                                   Corporation) 
 a public accountant enrolled with the New York State          other:  __________________________________________ 
  Education Department                                              
                                                                    
                                                                              __________________________________________ 
                                                                    
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TA-100 (06/17) 
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                                                           Petition 
 
Section IV         Petitioner Hereby Petitions for         [check appropriate box(es)] 
                                                                   
   redetermination of a deficiency/revision of a determination    review of revocation or denial of exempt status 
                                                                     
    refund                                                        other:  __________________________________________ 
                                                                     
   review of revocation or denial of a license, permit or           
   registration                                                                __________________________________________ 
                                                                     
Section V          Notice/Assessment Number(s) 
 
Please enter the notice/assessment ID number(s) being challenged.  NOTE:  A legible copy of the notice/assessment      must be attached 
to this petition.  
 
Notice/Assessment ID Number(s):  _____________________________________________________________________________ 
 
Section VI         The Tax in Question is  [check appropriate box(es)] 
 
  personal income tax (NYS – Article 22; NYC – NYC 
   Administrative Code, Title II, Chapter 17 or 19;                motor fuel tax (Article 12-A) 
   Yonkers – Article 30-A or 30-B) 
                                                                   highway use tax (Article 21) 
  sales and compensating use taxes (Articles 28 and 29) 
                                                                 
  corporation tax (Articles 9, 9-A, 13, 13-A, 27 and 33)          cigarette tax (Article 20) 
 
  other:  ________________________________________________________________________________________________ 
    
Section VII        Tax Determination 

    The amount of tax determined was:  _______________________________________________________________________ 

               The amount contested is:  _______________________________________________________________________ 
Where the controversy involves a refund, the amount(s) should be entered in parentheses, e.g., ($ 1,500). 

Section VIII       Reason(s) for Dispute 
The petitioner alleges that the Commissioner of Taxation and Finance made the following errors and asserts the following facts.  In 
separately numbered paragraphs, list each error of the Commissioner of Taxation and Finance that the petitioner intends to prove at the 
hearing.  Where necessary, additional pages may be added. 
 
___________________________________________________________________________________________________________ 
 
___________________________________________________________________________________________________________ 
 
___________________________________________________________________________________________________________ 
 
___________________________________________________________________________________________________________ 
 
___________________________________________________________________________________________________________ 
 
___________________________________________________________________________________________________________ 
 
___________________________________________________________________________________________________________ 
 
___________________________________________________________________________________________________________ 

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                                                                                Petition 
 
Section IX                Conciliation Conference with the Bureau of Conciliation and Mediation Services 
     A conciliation conference was not requested. 
       
     A conciliation conference was requested and the conciliation order was issued on (or the conciliation conference was 
       
      discontinued on):  ______________________________.  NOTE:  A copy of the conciliation order must be attached to this petition. 

Section X                 Small Claims Election –           see 20 NYCRR 3000.13  
Indicate whether you elect to proceed in the Small Claims Unit. 

     Petitioner wishes to have the proceedings conducted in the Small Claims Unit. 

For sales and compensating use tax, the amount in controversy for each 12-month period in question must not exceed $40,000 (not 
including penalty and interest); for all other taxes, the amount in controversy for each 12-month period in question must not exceed 
$20,000 (not including penalty and interest). 
 
A Small Claims Presiding Officer will conduct the hearing as informally as possible, consistent with orderly procedure.  The Presiding 
Officer will issue a determination within three months after completion of the hearing or submission of briefs, whichever is later.  The 
Presiding Officer’s determination is binding on both the petitioner and the Commissioner, and is not subject to review by any other unit 
in the Division of Tax Appeals, by the Tax Appeals Tribunal or by the courts. 
 
No other action has been commenced in the Division of Tax Appeals nor has any relief been previously granted with respect to any of 
the above stated items. 
 
WHEREFORE, the petitioner respectfully requests that this petition be granted.  The statements in this petition are made with the 
knowledge that a willfully false representation is a misdemeanor punishable under section 210.45 of the Penal Law. 
 
          ________________________________________________________         _____________________________ 
          Signature of Taxpayer or Taxpayer’s Representative  and* Title (if applicable)               Date 
 
          ________________________________________________________ 
          Print Name 
 
       * If this document is signed by any person other than the taxpayer, it must be accompanied by a duly executed Power of 
          Attorney unless:  (1) a Power of Attorney has already been filed with the Division of Tax Appeals, or (2) this document is 
          signed by an individual otherwise authorized to do so under the regulations of the Tax Appeals Tribunal (20 NYCRR 3000.2). 
 
CHECK APPROPRIATE BOX(ES) FOR DOCUMENTS THAT ARE ATTACHED: 
         Notice/Assessment 
         Power of Attorney (if applicable) 
         Conciliation Order (if applicable) 
 
This original petition, two identical copies and any required documents must be filed within the time limitations 
indicated on the Notice/Assessment.  This filing must be made with the Supervising Administrative Law Judge 
either in person at the address below or by mail addressed to: 
                                                                                 
                                                           Supervising Administrative Law Judge 
                                                            NYS Division of Tax Appeals 
                                                                   Agency Building 1 
                                                                   Empire State Plaza 
                                                            Albany, New York 12223 
 
      THE DIVISION OF TAX APPEALS CANNOT PROCESS THIS PETITION UNTIL ALL INFORMATION IS PROVIDED. 
                                        Please contact the Division of Tax Appeals with questions by calling (518) 266-3000.