Legal TFRP Appeal Form

LEGAL TFRP APPEAL FORM

Appellant Name:    Employer/Business Name:

Tax Identification Number (EIN or SSN):    Mailing Address:

Contact Phone:    Email:

Respondent Office Name:    Assessment / Case Number:

Assessment Date:    Assessment Amount: $    Tax Period(s):

RECITALS

WHEREAS, Respondent has issued an assessment characterized as a trust fund recovery penalty against Appellant in the amount set forth above by assessment number ; and

WHEREAS, Appellant seeks administrative review and judicial appeal of the assessment on the grounds set forth in this form and any accompanying statement of facts and legal argument; and

WHEREAS, the parties intend by this filing to preserve Appellant's rights to a full reconsideration or hearing consistent with applicable procedures and to identify the factual and legal bases for the appeal.

NOW THEREFORE, Appellant hereby submits the following appeal to the Respondent and certifies the statements herein.

1. JURISDICTION

Appellant asserts that this appeal is timely and properly before the Respondent under the procedures applicable to trust fund recovery penalty assessments. By submitting this form, Appellant requests adjudication by the appropriate review authority and reserves all rights to seek subsequent judicial review where permitted by law.

2. STATEMENT OF APPEAL

3. GROUNDS FOR APPEAL

Check all grounds asserted (select all that apply) and provide supporting details as necessary.

Incorrect identification of responsible person
Procedural error in assessment or notice
Insufficient evidence to support assessment
Other (explain below)

4. RELIEF REQUESTED

If monetary adjustment is requested, provide amount: $

5. SUPPORTING EVIDENCE

Check the documents included with this appeal (attach copies where required):

Payroll records
Bank statements
Corporate resolutions or minutes
Affidavits or sworn statements
Other supporting documents

6. REPRESENTATION

Yes    No

Authorization: I authorize the above-named representative to act on my behalf in this appeal, including receipt of notices and settlement communications.

7. TIMELINESS AND WAIVER

By filing this appeal, Appellant asserts that the appeal is timely under the applicable deadline and does not waive any procedural or substantive defenses except as expressly stated in writing. Failure to provide requested information may result in dismissal or denial of the appeal in whole or in part.

8. NOTICES

9. AMENDMENTS, WAIVER, COUNTERPARTS

This appeal may be amended in writing prior to a final adjudication. No waiver of any provision of this appeal will be effective unless in writing and signed by the party waiving the provision. This filing may be executed in counterparts, each of which constitutes an original, but all of which together constitute one and the same instrument.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

The interpretation and enforcement of this appeal shall be governed by the laws applicable to assessments of trust fund recovery penalties in the jurisdiction where the assessment arose. This form, together with any attached statement and supporting exhibits, constitutes the entire statement of appeal and supersedes any prior written or oral communications regarding the matters raised herein. If any provision of this appeal is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. DECLARATION AND CERTIFICATION

I declare under penalty of perjury that the information and statements contained in this appeal and any accompanying documents are true, correct, and complete to the best of my knowledge and belief. I understand that making a false declaration or submitting false documents may subject me to civil or criminal penalties.

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