Tax Assessment Notice

TAX ASSESSMENT NOTICE

Notice Number:    Assessment Date:

TAXPAYER IDENTIFICATION

Taxpayer Identification Number — provide either Social Security Number or Employer Identification Number: SSN:    EIN:

Individual/Sole Proprietor C Corp S Corp Partnership Trust/Estate LLC Other:

ASSESSMENT SUMMARY

Tax Period Beginning:    Ending:

Tax Type:

Tax Assessed: $    Adjustments/Credits Applied: $

Prior Payments/Credits: $    Interest Accrued: $    Penalties: $

Total Amount Due (now): $    Payment Due Date:

REVIEW, PAYMENT, AND APPEAL

You are hereby notified of the administrative assessment described above. You have the right to request an administrative review or hearing. A request for review must be received within days from the Assessment Date shown on this notice.

Select election: I accept the assessment and will remit payment in full.
I dispute the assessment and request administrative review/hearing (provide basis below).

If payment cannot be made in full, you may request a payment arrangement. Requesting a payment arrangement does not stay collection unless approved in writing.

CERTIFICATION

By signing below, I certify, under penalty of perjury, that:

1. The information provided on this Tax Assessment Notice is true, correct, and complete to the best of my knowledge.

2. I acknowledge receipt of this notice and understand the amount shown as Total Amount Due is subject to collection and may accrue additional interest and penalties if unpaid after the Payment Due Date.

3. If I dispute the assessment, the statements and documentation I provide in the dispute section above are complete and accurate, and I will cooperate in any administrative review or hearing.

4. I understand that knowingly making a false statement or omission in connection with this notice may subject me to civil or criminal penalties as provided by law.

Sign Now