Form IT-FA4 Petition for Review of Preliminary Assessment (Revised: April 2005) (fillable form)

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)