Form It-Pr - Petition For Reassessment Personal Income Tax - 2001
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1IT-PR
(Rev 02/01)
Petition for Reassessment
P
I
T
ERSONAL
NCOME
AX
Regarding the Personal Income Tax Assessment Against:
Name(s) ____________________________________________
Assessment Serial No. ________________________________
Address ____________________________________________
Tax Year(s) __________________________________________
City _____________________ State _____ Zip ____________
Date Assessed ____________ Date Received _____________
Social Security No. ____________________________________
Date Paid ___________________________________________
Spouse's Social Security No. ____________________________
Amount Paid _________________________________________
Note: Failure to comply with the Ohio Revised Code (ORC) section 5747.13 can result in dismissal of your petition. ORC
Sections 5747.13(B) and (E) may require payment of all or a portion of the assessment within sixty days of receipt
of the assessment. See important information on back of this form.
Indicate below your objections to the assessment. Attach additional sheets, if necessary.
Check one:
c
I waive a hearing.
(Please choose city from drop down box.)
c
I request a hearing in:
Columbus
Dayton
I will be represented in this matter by:
I am the party assessed or the authorized agent of the
(Complete if known. Type or print.)
party assessed, and I have knowledge of the relevant
facts in this matter.
Name ______________________________________________
Signature ________________________ Date _____________
Address ____________________________________________
Name ______________________________________________
City _____________________ State _____ Zip ____________
Title _______________ Telephone No. __________________
Telephone No. _______________________________________
For State Use Only
Please complete all blanks. Please type or print in ink.
Please file this petition in duplicate with:
Ohio Department of Taxation
Assessment Division
P.O. Box 1090
Columbus, OH 43216-1090
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