Petition Form - New York City Tax Appeals Tribunal Administrative Law Judge Division
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1
2FOR OFFICE USE ONLY
The City of New York
P E T I T I O N
NEW YORK CITY TAX APPEALS TRIBUNAL
EMPLOYER IDENTIFICATION NUMBER OR
ADMINISTRATIVE LAW JUDGE DIVISION
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
A legible copy of the Notice of Disallowance
Date of 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
...............................................
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