New York State Department of Taxation and Finance
                                                                                                                     DTF-911 
                        Request for Assistance from the                                                                                        (1/10)
                        Office of the Taxpayer Rights Advocate

Read instructions on page 2 before completing this form.

Taxpayer information
 Name (as shown on tax return)                                                                         Social security number (SSN)

 Spouse’s name (if applicable)                                                                         Spouse’s SSN

 Executor’s name (if applicable)                      Decedent’s name                                  Decedent’s SSN

 Current street address (number, street, and apartment number)

 City                                                                                     State (or foreign country) ZIP code

 Fax number                      E-mail address
 (      )
 Taxpayer identification number (if applicable)        Tax type                          Tax form(s)                 Tax period(s)

 Telephone number                    Best time to call                   Business’s contact person (if not representative on power of attorney)
 (      )

If you already have a power of attorney on file with the Tax Department, mark an  Xin the box ............................................................

Indicate if you have any special communications needs(Mark an  Xin the box.)

   TTY/TTD line                     Other (specify) : 

Describe the tax problem you are experiencing, how you previously tried to resolve the problem, and the Tax Department office(s) you 
contacted previously (see instructions for required information; attach additional sheets if necessary)

Describe the relief/assistance you are requesting (attach additional sheets if necessary)

Contacting third parties
In order to respond to your request, we may need to contact third parties. By signing below, you authorize the Office of the Taxpayer 
Rights Advocate to make these contacts. We won’t give you notice that we’re contacting these third parties.
 Signature of taxpayer or executor (if applicable)                                                                   Date

 Signature of spouse (if applicable)                                                                                 Date

 Printed name and signature of corporate officer                         Title                                       Date

Page 2 of 2 DTF-911 (1/10)

                                                      Instructions

The Office of the Taxpayer Rights Advocate (OTRA) is          Business contact person — If a business entity is filing 
an independent organization within the New York State         this form, enter the name of the person to contact about 
Department of Taxation and Finance. OTRA was created          the request. This may be the corporate officer signing 
to safeguard taxpayer rights and to assist taxpayers who      the request, or another person authorized to discuss the 
are experiencing problems with the Tax Department.            matter.

When to use this form                                         Power of attorney 
Use this form if you are experiencing any of the following    If you choose to have a representative act on your behalf, 
problems:                                                     you must complete a power of attorney form.
• You are facing a threat of immediate adverse action         Businesses: use Form POA-1, Power of Attorney
(e.g., seizure of an asset) for a debt you believe is not     Individuals: use Form POA-1-IND, Power of Attorney 
owed or where the action is, in your view, unwarranted,       for Individuals
unfair, or illegal.
                                                              Estates: use Form ET-14, Estate Tax Power of Attorney
• You are experiencing undue economic harm or are 
about to suffer undue economic harm because of your           You can get these forms from our Web site at 
tax problem.                                                  www.nystax.gov.
• You believe there has been an undue delay by the Tax        Include the power of attorney form when you submit this 
Department in providing a response or resolution to           form.
your problem or inquiry.
• You believe the tax laws, regulations, or policies are      Describe the tax problem you are experiencing
being administered unfairly or have impaired (or will         Enter any detailed information necessary to describe 
impair) your rights.                                          the tax problem you are experiencing. If you have 
• You believe a Tax Department system or procedure has        been involved with a Bureau of Conciliation and 
failed to operate as intended, or has failed to resolve       Mediation Services conference, a small claims hearing, 
your problem or dispute.                                      the Tax Appeals Tribunal, a courtesy conference, an 
• You believe that the unique facts of your case or           administrative law judge, an Offer in Compromise, or an 
compelling public policy reasons warrant assistance.          audit or other collection action, include the dates of such 
                                                              activity, as well as the following information (if applicable):
When not to use this form                                     • BCMS number
• If you haven’t exhausted all reasonable efforts to obtain   • DTA number
timely relief through normal Tax Department channels.         • audit case number
• To seek legal or tax return preparation advice.             • assessment or collection case number
• To seek review of an unfavorable administrative law         • formal or informal protest number
judge, Tax Appeals Tribunal, or judicial determination.
                                                              Where to file
Specific instructions                                         Send your completed Form DTF-911 and any required 
Taxpayer information                                          attachments to:
E-mail address — We may contact you by e-mail if we’re 
unable to reach you by telephone. We won’t use your           By mail — NYS TAX DEPT
e-mail address to discuss the specifics of your case.                               OTRA
                                                                                    W A HARRIMAN CAMPUS
Taxpayer identification — Enter your taxpayer                                       ALBANY NY 12227
identification number if this request involves a business     By fax — (518) 435-8532
or non-individual entity (e.g., a partnership, corporation, 
trust, or self-employed individual).
Tax type  — Enter the tax type (for example, personal 
income tax, corporation tax, sales tax, etc.) that relates to Privacy notification — The Commissioner of Taxation and Finance may collect and maintain 
                                                              personal information pursuant to the New York State Tax Law, including but not limited to, 
this request.                                                 sections 5-a, 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that Law; and 
                                                              may require disclosure of social security numbers pursuant to 42 USC 405(c)(2)(C)(i).
Tax form(s) — Enter the form number(s) that relates to        This information will be used to determine and administer tax liabilities and, when authorized 
this request. For example, an individual taxpayer with an     by law, for certain tax offset and exchange of tax information programs as well as for any other 
                                                              lawful purpose.
income tax issue might enter Form IT-201.                     Information concerning quarterly wages paid to employees is provided to certain state agencies 
                                                              for purposes of fraud prevention, support enforcement, evaluation of the effectiveness of certain 
Tax period(s) — Enter the quarterly, annual, or other tax     employment and training programs and other purposes authorized by law.
period(s) that relates to this request. For example, if this  Failure to provide the required information may subject you to civil or criminal penalties, or both, 
request involves an income tax issue, enter the calendar      under the Tax Law.
or fiscal year; if an employment tax issue, enter the         This information is maintained by the Manager of Document Management, NYS Tax 
                                                              Department, W A Harriman Campus, Albany NY 12227; telephone (518) 457-5181.
calendar quarter.