Form Apl-002 - Appellate Division Appeal Form
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1Department of Revenue Services
Form APL-002
Appellate Division
Appellate Division Appeal Form
25 Sigourney St Ste 2
Hartford CT 06106-5032
(Rev. 10/08)
Purpose: Form APL-002 may be used to fi le a written appeal with the Department of Revenue Services (DRS) Appellate Division.
Mail the completed Form APL-002 to the address above or fax it to 860-297-4780. For more information about Form APL-002,
visit the DRS website at If you need additional help, call 860-297-4775, Monday through Friday, during
business hours.
Taxpayer’s name
Social Security Number or Connecticut Tax Registration Number
Spouse’s name (if joint liability)
Spouse’s Social Security Number
Mailing address
City, state, and ZIP code
Physical address (number and street) (if different from above)
City, state, and ZIP code
Daytime telephone number
Case Identifi cation Number
Notice Number
(
)
Tax type(s)
For the period(s)
Name of authorized representative: Attach a copy of Form LGL-001.
Email address of representative
Basis for Appeal
As required by law, you must provide a written explanation of the grounds or basis for your appeal. Use the space below or use
additional sheets as necessary. Failure to provide an explanation of the grounds or basis of your appeal may result in denial of
your appeal.
I (we) are appealing the following issues:
1.
_______________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
2.
_______________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
3.
_______________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Signature of taxpayer or authorized representative
Title
Date
__________________________________________________________________________________________________________
Spouse’s signature (if joint liability)
Date
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Parent category: Financial