Hawaii Appeal Application

Appeal Application
Form AA-1, Rev. 2017, Appeal Application for the Administrative Appeals and Dispute Resolution Program
Clear Form

Form AA-1
(Rev. 2017)

STATE OF HAWAII — DEPARTMENT OF TAXATION

APPEAL APPLICATION

FOR THE ADMINISTRATIVE APPEALS AND DISPUTE RESOLUTION PROGRAM

IMPORTANT: Please use the separate instructions to complete this form.
Section 1

Your Information

Section 2

Your Representative (if any)

Tell us who you are and how to contact you. A person
requesting an appeal is called a “petitioner.”

If you want someone to represent you during this
appeal, complete this section and attach Form N-848.

Social security number(s) or FEIN

I appoint the following person(s) as attorney(s)-in-fact to represent me in this
appeal. I authorize my representative(s) to perform acts that I can perform
with respect to this appeal including receiving and inspecting my confidential
tax information, and signing agreements, consents, or similar documents.

Hawaii tax identification number

Name(s)

Verified Practitioner ID No. or Tax Matters Representative ID No.
Name(s)

DBA (Doing Business As)

Firm’s name

Mailing address

Mailing address

City, town or post office

State

Postal/ZIP code

Daytime phone number

Fax number

Email address

City, town or post office

State

Daytime phone number

Fax number

Postal/ZIP code

Email address

Section 3

Information About Your Appeal

Tell us about the assessment(s) that you dispute.
3a. Check one box to indicate the type of assessment you are appealing: 3b. Tax year(s)

Tax type (e.g., income, GE) Assessment mailing date

FF Notice(s) of Proposed Assessment
FF Notice(s) of Final Assessment
FF Notice and Demand of Penalty (preparer penalties)
3c. Auditor’s or examiner’s name

3d. Branch

3e. Branch location

 Field Audit  Office Audit

 Oahu

 Maui

 Kauai

 Hawaii

3f. Did you file an appeal with the Board of Review?  Yes  No
3g. Did you file an appeal with the Tax Appeal Court?  Yes  No (If you checked “Yes,” you must have permission
from the Tax Appeal Court to participate in AADR. Attach a copy of the Court permission or pending motion/stipulation.)
Section 4

Reason for Your Appeal

List the item(s) that you disagree with and explain the reason(s) you think the assessment(s) is incorrect. If you
need more space, attach additional sheets.
Disagreed item(s)

Reason(s) why you disagree and the relief that you are seeking

Form AA-1

Page 2

Form AA-1
(Rev. 2017)
Section 5

Statement of Facts

State the facts and the law or other legal authority, if any, to support your position on each disagreed item. If you
need more space, attach additional sheets.

Section 6
Signature of Petitioner(s)
Other Requirements: Check off each box to indicate that you have fulfilled
the requirements below. Your application may be rejected or delayed if you
don’t fulfill these requirements. Do not submit your tax return, receipts, or
other types of evidence with this application.
FF I enclosed a copy of each Department of Taxation assessment that I dispute
with this application.
FF I provided a copy of this application including any accompanying documents
to the Department of Taxation auditor or examiner assigned to my case.

Mail your application to:
Hawaii Department of Taxation
Administrative Appeals Office
830 Punchbowl Street, Room 221
Honolulu, HI 96813-5094

I declare that the information in this application and any accompanying documents are true, correct, and complete to the
best of my knowledge and belief.
Signature of Petitioner(s)

Print name(s) and title(s)

Date


	
To Be Completed by the Administrative Appeals Office
Date application received

Was this application filed timely?
​	Yes	
​	No

Case number

Date case closed

Form AA-1