Pennsylvania Board of Appeals Petition Form

Board of Appeals Petition Form
Board of Appeals Petition Form (REV-65)
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
6500022105
(BA+) 01-24

REV-65

OFFICIAL USE ONLY

BOARD OF APPEALS
PO BOX 281021
HARRISBURG PA 17128-1021

START

➜

SECTION I

BOARD OF APPEALS
PETITION FORM

TAX INFORMATION
MM/DD/YYYY

Tax Type Appealed (select one):

Tax Period Begin Date

Personal Income Tax

Corporation Tax

Sales/Use Tax

Employer Withholding

Inheritance Tax

PTRR

Type of Petition:

Refund

Tax Period End Date

Reassessment/Review

FOR REFUND PETITION ONLY:
Cash

Other

If petition is in regard to sales tax, please list amount(s) below:

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

Paid:

Yes

Are there any current
audits for this taxpayer
or tax period?

SECTION II

Penalty/Fees Assessment Amount

MM/DD/YYYY

If paid, date paid
Yes

Are there any current
appeals for this taxpayer
or tax period?

Audit Number

No

Yes

Docket Number

No

PETITIONER INFORMATION

Individual
Estate

No

Tax Assessment Amount

Corporation

Partnership (attach list of partners & addresses)

Other

MM/DD/YYYY

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

SECTION III

ZIP Code

REPRESENTATIVE INFORMATION

Company Name

Telephone Number

Contact Last Name

Contact First Name

Email Address

Address

City

State

6500022105
RESET FORM

Country Code

TOP OF PAGE

ZIP Code

Country Code

6500022105

PAGE 1

NEXT PAGE

PRINT

6500022205

REV-65 (BA+) 01-24

SECTION IV
Hearing Requested

SCHEDULING REQUEST
No Hearing Requested. Please decide on basis of the petition and record.

This case to be held pending action on the same issue(s).

SECTION V

Court Citation
Number

Case
Number

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.
Petitioner’s Name

Petitioner’s Signature

Petitioner’s Title

Date

Representative’s Title

Date

MM/DD/YYYY

PLEASE SIGN AFTER PRINTING

Representative’s Name

Representative’s Signature

PLEASE SIGN AFTER PRINTING

6500022205

RESET FORM

PREVIOUS PAGE

6500022205

PAGE 2

NEXT PAGE

PRINT

Instructions for REV-65

Board of Appeals Petition Form

REV-65 IN (BA+) 01-24

For video information on the Board of
Appeals procedures and for additional
details on the Board of Appeals Petition
Form (REV-65), please follow this QR Code
to informational videos on these topics.

GENERAL INFORMATION
Please type or print neatly in blue or black ink. Attach a copy
of the notice being appealed.
The fill-in form must be downloaded to your computer prior
to completing.
Petitions should be sent directly to the Board of Appeals
online or by mail. Please be aware that the Board of Appeals
does not accept petitions by email or fax. The preferred
method of filing is online because this method is the only
method that provides an immediate confirmation number.
Online petitions are filed through the Board of Appeals
website: revenue.pa.gov/taxappeals. The mailing address
for the Board of Appeals is:
BOARD OF APPEALS
PO BOX 281021
HARRISBURG PA 17128-1021
Petition is considered filed as of the USPS postmark date.
Meter dates (ex: Pitney Bowes) or any other non-USPS
mark (ex: FedEx, UPS) are not recognized.
Failure to include any required information may result in a
dismissal of your appeal.
COMPROMISE
The Board of Appeals will consider compromises of
assessment and refund appeals. If you wish to propose a
compromise, please complete and submit a Request for
Compromise (DBA-10) with your petition or within 30 days
from the date the petition is filed. Further instructions
regarding Compromises may be found in the instructions for
the DBA-10 Form.

Administrative Appeals of Record such as revocation of a
lottery license.
TAX PERIOD BEGIN AND END DATES
Please clearly identify the tax period being appealed. Please
use a MM/DD/YYYY format.
TYPE OF PETITION
Fill in only one oval for the type of petition. Do not mark both.
PETITION FOR REFUND
Provide refund form (cash or credit) and the specific refund
amount requested. If the refund requested is for sales tax,
provide requested amounts for PA tax refund. If applicable,
provide amounts for Philadelphia tax refund or Allegheny
County tax refund.
PETITION FOR REASSESSMENT/REVIEW
Provide the Assessment Letter ID, the Assessment Letter
Mail Date, tax assessment amount, and penalty/fees
assessment amount. If the tax assessment amount and
penalty/fees assessment amount have been paid in full,
provide date paid.
CURRENT APPEALS AND AUDITS
If there are any current audits for this taxpayer or tax period,
provide the Audit assessment number and/or audit
assignment number. If there are any current tax appeals for
this taxpayer or tax period, provide the docket number(s).
This section is applicable to petitions for refund and petitions
for reassessment/review.

SECTION II
PETITIONER INFORMATION
Fill in the oval to identify whether you are an individual,
corporation, partnership, estate, or other. If the appeal is on
behalf of an Estate, please proved the date of death for the
decedent.

SECTION I

SSN/FEIN
Social Security number is required for Individual, Estate and
Partnership appeals. Include Social Security number for
each partner when providing list of partner names and
addresses.

TAX INFORMATION
TAX TYPE APPEALED
Fill in the oval for the Pennsylvania tax type being appealed.
The Other category includes many tax types including
Realty Transfer Tax, Fuels Taxes, Gaming Taxes, and

NOTE: The department is authorized under federal
law, 42 U.S.C. § 405 (c), to use your Social Security
number in administering state tax law. The department uses
your Social Security number to establish your identity and
to process your appeal.

LINE INSTRUCTIONS

revenue.pa.gov
PREVIOUS PAGE

REV-65
NEXT PAGE

PRINT

1

Federal employer identification number is issued by the IRS
to business entities. Complete this number if one has been
assigned to you.

Any changes to Board of Appeals hearing procedures will
be posted to the Board of Appeals website:
revenue.pa.gov/taxappeals

ACCOUNT ID
Account ID Number is the number used to identify the tax
account being appealed. This number may be available on
the Assessment Notice.

SECTION V

SECONDARY ID
Additional Departmental issued number assigned to each
taxpayer or business entity with a filing requirement in
Pennsylvania. Examples include the Sales Tax License
Number, Estate File Number or Control Number.
COUNTRY CODE
The Country Code is a two-character alphabetic
abbreviation for the country. Codes can be found at
irs.gov/e-file-providers/foreign-country-code-listingfor-modernized-e-file under the country codes menu
selection.

SECTION III
REPRESENTATIVE INFORMATION
Representation by an attorney, CPA or other person is not
required. Complete representative information only if
Petitioner is represented by another person.
COUNTRY CODE
The Country Code is a two-character alphabetic
abbreviation for the country. Codes can be found at
irs.gov/e-file-providers/foreign-country-code-listingfor-modernized-e-file under the country codes menu
selection.

SECTION IV
SCHEDULING REQUEST
Hearings are not required. However, if you wish to request
a hearing, you must fill in the Hearing Requested oval. All
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

CORRESPONDENCE WITH BOARD OF APPEALS
Please select desired method of correspondence. You may
only select one option from each column (for example you
may only select US Mail or Email, but not both).
NOTE: Communication, including the board’s final
decision and order, may be transmitted to you or your
representative via email, should you elect the email option.
If you elect to receive communications via email, you and
your representatives assume the responsibility for the
confidentiality of the information contained in emails sent to
and from the Board of Appeals. The commonwealth will not
be held liable for the disclosure of any confidential
information sent via email.

SECTION VI
ISSUES AND ARGUMENTS
Briefly state the issue(s) involved and explain in detail why
relief should be granted. Additional pages may be attached,
if necessary.
Any required appeal schedule should be submitted with the
petition or within 30 days of the date that the petition is filed.
Any evidence in support of the petition may be submitted
with the petition but no later than 60 days from the date that
the petition is filed.

SECTION VII
CERTIFICATION
All petitions must be signed by the Petitioner and/or
Authorized Representative. A Power of Attorney (REV-677)
must be submitted if the petition is only signed by the
authorized representative.

REV-65

PREVIOUS PAGE

revenue.pa.gov
TOP OF FORM

PRINT