Additional Evidence or Information Attached
Yes No
(Social Security Number or FEIN)
Address
ALABAMA DEPARTMENT OF REVENUE
Do you wish to schedule a conference during which you may present your position to the Department? (If you mark yes you will be notified in writing of a date and time for a conference )
Explain below the reason(s) why you disagree with the Preliminary Assessment entered by the Department (Attach additional sheets if necessary )
I disagree with the Preliminary Assessment issued against me for the reason(s) detailed above and hereby file this Petition for Review
If you have additional evidence or information which will support your objections to the Preliminary Assessment check the block and attach photocopies
IT: FA4
NOTE: If this is an appeal by a corporation an authorized officer must sign An appeal by a partnership requires the
of Preliminary Assessment
OffOff
Period Covered
Petition For Review
Questions may be directed to the Alabama Department of Revenue at telephone number (334) 353 8187
signature of a partner
Signature of Joint Taxpayer or Representative Date
Signature of Taxpayer or Representative Date (Representative Must Attach Power of Attorney)
Taxpayer s ID Number
Taxpayer s Name
Telephone Number ( Account Number
This form must be completed and mailed to the address on the Preliminary Assessment within thirty (30) calendar days of the entry of the Preliminary Assessment
Title
Total Amount Assessed
Type of Tax(es)
