NC-TA Web 3-14	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 XXX-XX-

Business Name Federal Employer ID Number XX-XXX

Current Street Address

City State Zip Code AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY

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.