Please type or print clearly in blue or black ink Note that a compromise will only be considered when it illustrates doubt regarding liability andor it promotes effective tax administration Compromises addressing any of the following will not be con ID: 42882
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START Ü MM/DD/YYYY Please sign after printing. Please sign after printing. PRINT NEXT PAGE TOP OF PAGE PETITIONER & REPRESENTATIVE INFORMATION SECTION I COMPROMISE INFORMATION SECTION III Taxpayer ID Board of Appeals Docket Number, if available Petitioner AddressPetitioners representative and address, if applicable ZIP Code Representative Address ZIP Code Type of AppealTax Period(s) Amount at Issue State the offer in compromise and the reason(s) for requesting the compromise. Attach additional pages if necessary.Enclose copies of any documentation that supports the offer in compromise. Compromise Amount APPEAL INFORMATION Petitioner acknowledges that if the aforementioned appeal is compromised, a compromise order will be issued and petitioner waives any right to:claim any refund of money paid pursuant to the compromise order;claim any refund of the self-reported tax; orfile any petition or appeal that raises the same issues for the tax period(s) and liability(ies) addressed in the compromise order. SIGNATURES SECTION IV Petitioner Signature DBA-10 (BA) 04-19 BOARD OF APPEALS REQUEST FOR COMPROMISE HARRISBURG PA 17128-1021 DBA-10 www.revenue.pa.gov an appeal to the Board of Appeals, preferably alongwith the Board of Appeal petition form, or as soon asThe Compromise Request MUST clearly state thenecessary.A compromise request will only be considered whenliability and/or (2) the compromise promotes effectiveoffer in compromise include the following: theExample of doubt as to liability: You were audited byassessment. You are unable to reconstruct yourAppeals pursuant to the Gaming Control Act will notAny offer of zeroŽ or noneŽ will not be considered. inability to pay) will not be considered by the Board of Appeals. € If Petitioner has not filed all Pennsylvania tax returns, a compromise request will not be considered. € If a criminal prosecution is pending, a compromise request will not be considered. GENERAL INSTRUCTIONS WHAT MAY BE COMPROMISED WHAT WILL NOT BE COMPROMISED Pennsylvania Department of Revenue Board of Appeals Request for CompromiseDBA-10 IN (BA) 04-19 THIS PAGE DOES NOT PRINT RETURN TO FORM