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            IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING

                                                                       6500022105
                                           (BA+) 01-24
                                                                                                           OFFICIAL USE ONLY
                            REV-65 
                            BOARD OF APPEALS                    BOARD OF APPEALS 
                            PO BOX 281021 
                            HARRISBURG PA 17128-1021                   PETITION FORM

START SECTION I                TAX INFORMATION
                                                                                                                                        MM/DD/YYYY
Ü     Tax Type Appealed (select one):                                                                                         Tax Period Begin Date
      Personal Income Tax             Corporation Tax      Sales/Use Tax
      Employer Withholding            Inheritance Tax      PTRR                  Other                                        Tax Period End Date

      Type of Petition:        Refund     Reassessment/Review
      FOR REFUND PETITION ONLY:
                                                           If petition is in regard to sales tax, please list amount(s) below:
      Cash    Total Refund Requested                       PA Tax Refund         Philadelphia Tax Refund                      Allegheny County Tax Refund
      Credit

      FOR REASSESSMENT/REVIEW PETITION ONLY:               MM/DD/YYYY
      Assessment Letter ID            Assessment Letter Mail Date        Tax Assessment Amount                         Penalty/Fees Assessment Amount

                                           MM/DD/YYYY
      Paid:   Yes              No     If paid, date paid

      Are there any current       Yes Audit Number                               Are there any current          Yes    Docket Number
      audits for this taxpayer                                                   appeals for this taxpayer 
      or tax period?              No                                             or tax period?                 No

      SECTION II               PETITIONER INFORMATION

      Individual               Corporation              Partnership (attach list of partners & addresses)       Other
                                                                       MM/DD/YYYY
      Estate         Date of Death (required for estates & 
                     personal income tax fiduciary appeals)
      Legal Name (for individual applicants give your full legal name)              SSN/FEIN                                  Account ID

      Trade Name or DBA (if different from Legal Name)                              Secondary ID (see instructions)           Telephone Number

      Contact Last Name                                    Contact First Name                             Email Address

      Address                                              City                                           State ZIP Code                Country Code

      SECTION III              REPRESENTATIVE INFORMATION
      Company Name                                                                                                            Telephone Number

      Contact Last Name                                    Contact First Name                             Email Address

      Address                                              City                                           State ZIP Code                Country Code

                                      6500022105                                                                6500022105

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6500022205

REV-65 (BA+) 01-24

SECTION IV SCHEDULING REQUEST
Hearing Requested No Hearing Requested. Please decide on basis of the petition and record.
Case Court Citation
This case to be held pending action on the same issue(s). Number Number
SECTION V CORRESPONDENCE WITH THE BOARD OF APPEALS
If you elect to receive communications via email, you are authorizing the Board of Appeals to send correspondence, including the final Decision & Order,
via email.
Send Correspondence to (select one): Petitioner Representative
Send Correspondence via (select one): U.S. Mail Email
Send Decision and Order via (select one): U.S. Mail Email

SECTION VI ISSUES & ARGUMENTS
Itemize the issue(s) involved. What is the subject of appeal? Attach a separate sheet if more space is required.

SECTION VII CERTIFICATION
ALL APPLICANTS MUST COMPLETE THIS SECTION
All petitions must be signed by the petitioner or authorized representative. If signed only by an authorized representative, written authorization must
accompany the petition. If the petitioner is a corporation, a corporate officer must sign.
Under penalties prescribed by law, I hereby certify this petition has been examined by me, and to the best of my knowledge, information and belief, the
facts contained in the petition are true, correct and complete and the petition is not made for the purpose of delay. Also, if this is a petition for refund, I
certify that the refund requested has not been granted in an audit report, nor has it been included in any other petition for refund.
MM/DD/YYYY
Petitioner’s Name Petitioner’s Signature Petitioner’s Title Date
PLEASE SIGN AFTER PRINTING
Representative’s Name Representative’s Signature Representative’s Title Date
PLEASE SIGN AFTER PRINTING

6500022205 6500022205

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Instructions for REV-65
REV-65 IN (BA+) 01-24 Board of Appeals Petition Form

For video information on the Board of Administrative Appeals of Record such as revocation of a
Appeals procedures and for additional lottery license.
details on the Board of Appeals Petition
TAX PERIOD BEGIN AND END DATES
Form (REV-65), please follow this QR Code
to informational videos on these topics. Please clearly identify the tax period being appealed. Please
use a MM/DD/YYYY format.
GENERAL INFORMATION TYPE OF PETITION
Please type or print neatly in blue or black ink. Attach a copy Fill in only one oval for the type of petition. Do not mark both.
of the notice being appealed. PETITION FOR REFUND
The fill-in form must be downloaded to your computer prior Provide refund form (cash or credit) and the specific refund
to completing. amount requested. If the refund requested is for sales tax,
Petitions should be sent directly to the Board of Appeals provide requested amounts for PA tax refund. If applicable,
online or by mail. Please be aware that the Board of Appeals provide amounts for Philadelphia tax refund or Allegheny
does not accept petitions by email or fax. The preferred County tax refund.
method of filing is online because this method is the only PETITION FOR REASSESSMENT/REVIEW
method that provides an immediate confirmation number. Provide the Assessment Letter ID, the Assessment Letter
Online petitions are filed through the Board of Appeals Mail Date, tax assessment amount, and penalty/fees
website: revenue.pa.gov/taxappeals. The mailing address assessment amount. If the tax assessment amount and
for the Board of Appeals is: penalty/fees assessment amount have been paid in full,
provide date paid.
BOARD OF APPEALS
PO BOX 281021 CURRENT APPEALS AND AUDITS
HARRISBURG PA 17128-1021 If there are any current audits for this taxpayer or tax period,
Petition is considered filed as of the USPS postmark date. provide the Audit assessment number and/or audit
Meter dates (ex: Pitney Bowes) or any other non-USPS assignment number. If there are any current tax appeals for
mark (ex: FedEx, UPS) are not recognized. this taxpayer or tax period, provide the docket number(s).
This section is applicable to petitions for refund and petitions
Failure to include any required information may result in a
for reassessment/review.
dismissal of your appeal.

COMPROMISE SECTION II

The Board of Appeals will consider compromises of
PETITIONER INFORMATION
assessment and refund appeals. If you wish to propose a
compromise, please complete and submit a Request for Fill in the oval to identify whether you are an individual,
Compromise (DBA-10) with your petition or within 30 days corporation, partnership, estate, or other. If the appeal is on
from the date the petition is filed. Further instructions behalf of an Estate, please proved the date of death for the
regarding Compromises may be found in the instructions for decedent.
the DBA-10 Form. SSN/FEIN
Social Security number is required for Individual, Estate and
LINE INSTRUCTIONS Partnership appeals. Include Social Security number for
each partner when providing list of partner names and
SECTION I addresses.

TAX INFORMATION NOTE: The department is authorized under federal
TAX TYPE APPEALED law, 42 U.S.C. § 405 (c), to use your Social Security
Fill in the oval for the Pennsylvania tax type being appealed. number in administering state tax law. The department uses
The Other category includes many tax types including your Social Security number to establish your identity and
Realty Transfer Tax, Fuels Taxes, Gaming Taxes, and to process your appeal.

revenue.pa.gov REV-65 1

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Federal employer identification number is issued by the IRS Any changes to Board of Appeals hearing procedures will
to business entities. Complete this number if one has been be posted to the Board of Appeals website:
assigned to you. revenue.pa.gov/taxappeals
ACCOUNT ID
SECTION V
Account ID Number is the number used to identify the tax
account being appealed. This number may be available on CORRESPONDENCE WITH BOARD OF APPEALS
the Assessment Notice. Please select desired method of correspondence. You may
SECONDARY ID only select one option from each column (for example you
Additional Departmental issued number assigned to each may only select US Mail or Email, but not both).
taxpayer or business entity with a filing requirement in NOTE: Communication, including the board’s final
Pennsylvania. Examples include the Sales Tax License decision and order, may be transmitted to you or your
Number, Estate File Number or Control Number. representative via email, should you elect the email option.
COUNTRY CODE If you elect to receive communications via email, you and
your representatives assume the responsibility for the
The Country Code is a two-character alphabetic
confidentiality of the information contained in emails sent to
abbreviation for the country. Codes can be found at
and from the Board of Appeals. The commonwealth will not
irs.gov/e-file-providers/foreign-country-code-listing-
be held liable for the disclosure of any confidential
for-modernized-e-file under the country codes menu
information sent via email.
selection.

SECTION VI
SECTION III

ISSUES AND ARGUMENTS
REPRESENTATIVE INFORMATION
Briefly state the issue(s) involved and explain in detail why
Representation by an attorney, CPA or other person is not
relief should be granted. Additional pages may be attached,
required. Complete representative information only if
if necessary.
Petitioner is represented by another person.
Any required appeal schedule should be submitted with the
COUNTRY CODE
petition or within 30 days of the date that the petition is filed.
The Country Code is a two-character alphabetic Any evidence in support of the petition may be submitted
abbreviation for the country. Codes can be found at with the petition but no later than 60 days from the date that
irs.gov/e-file-providers/foreign-country-code-listing- the petition is filed.
for-modernized-e-file under the country codes menu
selection.
SECTION VII

SECTION IV CERTIFICATION

All petitions must be signed by the Petitioner and/or
SCHEDULING REQUEST
Authorized Representative. A Power of Attorney (REV-677)
Hearings are not required. However, if you wish to request must be submitted if the petition is only signed by the
a hearing, you must fill in the Hearing Requested oval. All authorized representative.
hearings are currently held virtually using Microsoft Teams.
If you do not have access to Microsoft Teams a dial-in
conference call number will be provided. Petitioners may
request a phone conference in lieu of a hearing. It is at the
Board’s discretion whether to grant this request.

2 REV-65 revenue.pa.gov

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