(A) Instructions.
(1) This form is to be used by taxpayers appealing an assessment of tax by the Tax Administrator or an appeal of a denial of a claim for refund by the Tax Administrator. Please complete petition using blue or black ink, or type petition. Attach a copy of the assessment notice being appealed, or if seeking a refund, proof that such tax was paid. Mail this petition to the Secretary, the Township Office, R.R. 5, Box 39, Selinsgrove, PA 17870.
(2) Petitions appealing an assessment notice must be received by the Board of Supervisors within 90 days of the date of the assessment notice. Petitions for refunds must be received by the Board of Supervisors within the later of: three years of the due date for filing the return or one year after actual payment of the tax. Petitions filed via U.S. Postal Service are considered filed as of the postmark date. Petitions filed via any other method are considered filed on the date received. Answer all questions below as completely as possible. If an item is not applicable, enter “N/A”.
(B) Taxpayer information.
Last Name First Name Middle Initial
Street Address:
City State County Zip Code
Phone Number: ( ) - Fax Number: ( ) -
Previous Street Address (if applicable):
City State County Zip Code
Social Security No.
Taxpayer Identification No.
(C) Tax information.
Type of tax:
Is this petition for a refund? Yes No If so, what amount? $
Tax year Quarter:
Assessment notice mailing date:
School district:
Borough:
Township:
City:
Town:
County:
(D) Tax representative information. Complete information for tax representative (if applicable).
Send all copies of correspondence to: Representative
Last Name First Name Middle Initial
Is Representative Attorney Certified Public Accountant Other Accountant
Other Tax Advisor
Business Name:
Street Address:
City State County Zip Code
Phone Number: ( ) - Fax Number ( ) -
(E) Hearing request. Note: this division (E) can be eliminated if the Appeals Board is the Board of Supervisors acting in executive session.
Hearing requested (check if taxpayer desires a hearing in person)
Hearing requested based on petition and record (no hearing will be conducted in person)
(F) Relief requested and arguments.
Explain the relief requested:
Explain in detail why the relief requested above should be granted. Attach additional pages if necessary. Enclose copies of any documents you feel will support your arguments. Petitions for refund must be accompanied by proof of payment of the tax.
(G) Signature. All petitions must be signed by petitioner or an authorized representative. If signed by an authorized representative, written authorization for the representative to sign on petitioner’s behalf must accompany the petition. Under penalties prescribed by law, I hereby certify that this petition has been examined by me and that to the best of my knowledge, information, and belief, the facts contained in the petition are true and correct.
Signature:
(Taxpayer or Authorized Representative)
Print Name:
(Taxpayer or Authorized Representative)
Title:
Date:
(Ord. 1999-3, passed 12-21-1999)