Form Pdo-101 - Consent To Extend The Statutory Period For Assessing And Refunding Minnesota Tax - 2013

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Consent to Extend the Statutory Period
PDO-101
for Assessing and Refunding Minnesota Tax
For petroleum taxes
If we ask you to complete this consent form and you do not sign and return it, your tax liability may be adjusted based on available information.
Name
Minnesota tax ID number
Street address
City
State
Zip code
The above taxpayer and the Minnesota Department of Revenue agree that:
• Any petroleum taxes due under any return filed by or for the taxpayer for the period ended (month/day/year)
to
may be adjusted under Minnesota law within
after the following date (month/day/
year)
.
• The taxpayer waives the right to use any Minnesota statute of limitations as a basis to contest any adjustment.
If you authorize someone to sign on your behalf, you must attach Form REV184, Power of Attorney, which is available on the depart-
ment’s website at
Individuals: This form must be signed by you and by a representative of the Minnesota Department of Revenue.
Corporations: This form must be signed by an authorized corporate officer and by a representative of the Minnesota Department of
Authorized signature
Title (if corporate officer)
Date
Daytime phone
Send TWO COPIES of this form to the following address
Minnesota Revenue
Special Taxes - Petroleum Tax
Mail Station 3333
St. Paul, MN 55146-3333
Minnesota Department of Revenue Approval
Signature of department representative
Date
Title
Daytime phone
This form is not valid unless signed by an authorized representative of the Minnesota Department of Revenue.
(Rev. 3/13)

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