Review Board Appeal Petition 

  Form 50-001-10 
 
The Review Board hears appeals from taxpayers who disagree with certain actions of the agency.  This form must be completed and 
received by the Review Board within the time provided for your appeal to be filed and a hearing scheduled.  The mailing address for the 
Review Board is at the bottom of this page.  Attach a copy of the notice, assessment, denial of refund, denial of waiver of tag penalty, or 
intent to revoke or suspend a permit, license, registration, credentials, title, or tag that you are appealing.  
                                                                                                                                                                                           
Instructions:  Please type or print in ink.  Mail the completed form to the address below.  If the form is not complete, the Board of Review will return the form for completion.  The form 
must be completed and received by the Review Board within the time period allowed.  The Board may reject an appeal if information concerning the reason for disagreement with the 
assessment or notice and reasons why relief is requested is not provided.  An appeal may be rejected if the Board determines that the matter falls outside the Board’s authority An    .  
appeal for an assessment of tax, penalty, and/or interest, a denial of refund or denial of a waiver of a tag penalty must be received within 60 days from the date of the assessment or 
notice.  An appeal concerning a notice of intent to revoke or suspend a permit, license, registration, credentials, title or tag must be received within 30 days from the date of the notice.  
Information concerning the appeal process may be found at www.dor.ms.gov under Publications.  
                                                                                                                                                                                           
TAXPAYER REQUESTING THE APPEAL    
Name:                                                                                                             FEIN/SSN:  
Trade Name of Business, if applicable:  
Address:   
City, State, Zip:   
Phone Number:                                                   Email:                                                      FAX:   
Contact Person:                                                                                                            Title: 
                                                                                                                                                                                           
ISSUE(S) BEING APPEALED.  Check all that apply.  Review Board will NOT consider payment terms as an issue. 
 
       Audit results                           Assessment of tax                                            Interest assessed               Penalty assessed           
       Denial of Refund              Intent to revoke or suspend a permit                                   Title                                  Tag Penalty                  
       Other (list)   

Explain the reason for your appeal.  Explain in detail why you disagree with the DOR determination and why the issue(s) listed above should be decided in your favor.  
Attach additional pages if necessary.  State the facts on which you base your disagreement.  Provide, if known, the law, rules, or cases in support of your arguments.  Please be careful 
not to simply state the “assessment is too high” or the “assessment is wrong,” but, provide specific reasons for your belief.  You are not required to submit any evidence with this petition, 
but specific evidence supporting your position should be presented at the hearing.  Please do not submit tax forms, receipts, invoices or other types of evidence with this petition.  
  
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Any documentation not presented to the auditor during the audit should be provided to the auditor prior to the hearing.  

Review Board             P.O. Box 22828                    Jackson, MS  39225                 Phone:  601-923-7440               FAX:  601-923-7844 
 

Tax Information           List each/all tax account number(s) you want included in this appeal.  Attach additional pages if necessary.  Only the account numbers listed below are 
considered at the hearing.    
                                              Tax Account Number                                           Amount Contested                             Tax Periods  
        Sales Tax                             ___________________                                         $ ________________                   ____________________            
        Use Tax                               ___________________                                         $ ________________                   ____________________   
        Special City, County                  ___________________                                         $ ________________                   ____________________   
        Withholding                           ___________________                                         $ ________________                   ____________________   
        Corporate Income                      ___________________                                         $ ________________                   ____________________   
        Corporate Franchise                   ___________________                                         $ ________________                   ____________________   
        Individual Income                     ___________________                                         $ ________________                   ____________________   
        Petroleum                             ___________________                                         $ ________________                   ____________________   
        Transfer Assessment                   ___________________                                         $ ________________                   ____________________  
        Other (list)                          ___________________                                         $ ________________                   ____________________  

What decision do you request the Board to make?  
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 Representative  Representation by an attorney, CPA or other person is not required.  A power of attorney authorizing the representative to act for the taxpayer must be included 
with this form.   Form 21-002 may be found at www.dor.ms.gov under “Forms.”  
  
Is the taxpayer represented by another party?               No                 Yes     If yes, complete the following:  
    
Representative Name(s):                                                                                                                         
Firm, if applicable:  
Address:   
City, State, Zip:   
Phone Number:                                        Email:                                                                             FAX:   
Relationship to Taxpayer:                                                                                                                 
                                                                                                                                                                                    
Please provide name and mailing address where you desire to receive all correspondence regarding this appeal.  
 
                                                                                                  Taxpayer, address above  
Send Correspondence, Decision, and Order to:                                                      Representative, address above  
                                                                                                  Other:  
                                                                                                                                                                                   
I hereby certify that I am the taxpayer named above or I am the owner, corporate officer, member, partner or other representative of the above 
named taxpayer.  I also certify that I am authorized to execute this form on behalf of the taxpayer.  The representative named above is authorized to 
receive confidential tax information from the DOR on all matters raised on appeal.  
  
Signature:                                                                                                                                     Date:  
 
Print Name:   

Review Board             P.O. Box 22828                    Jackson, MS  39225                 Phone:  601-923-7440                  FAX:  601-923-7844