Request for Assistance
Office of the Taxpayer Advocate
North Carolina Department of Revenue
Part 1. Taxpayer Information
First Name M.I. Last Name Social Security Number
Business Name Federal Employer ID Number
Current Street Address
City State Zip Code
Daytime Telephone Number Email Address
Part 2. Assistance Information
Tax Type Tax Year(s)/Period(s)
Describe the tax problem you are experiencing, how you previously tried to resolve the problem, and the Division office(s) you contacted previously (attach additional sheets if necessary)
Describe the relief/assistance you are requesting (attach additional sheets if necessary)
By submitting this form I hereby,
  • Certify that, to the best of my knowledge, this form is accurate and complete.
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