Tax Assessment Reconsideration Request Form

Taxpayer Full Name

First NameMiddle NameLast Name

Organization or Business Name (if applicable)

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Tax Authority or Department Name

Assessment Notice or Reference Number

Tax Type

Tax Year or Period Being Challenged

Original Assessment Date

Date

Main Reason for Reconsideration

Detailed Explanation of the Issue

Amount Disputed

Amount Believed to Be Correct

Supporting Documents Attached

Supporting Documents

Upload Supporting Evidence

Brief Summary of Evidence

Declaration of Accuracy

Other

Signature