PETITIONER:      
          REV-39 BA (06-01-17) Rev                                                                                                                                                                                                                                                                                                            
                                                                                                                                                                                                          SALES AND USE TAX                                                                                                                    
                                                                                                                                                                                                           APPEAL SCHEDULE DOCKET NO:                                     
                                                                                         SECTION I (REQUIRED)                                                                                                                               SECTION II (REQUIRED)                                                                                        SECTION III (REQUIRED)                                                                                         (BOARD USE ONLY)
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                                                                                                                                                                                                                                                                                                                      Refund Requested Amount                                                                                                               BOARD OF APPEALS USE
                                                                                                                                                                                                                                                               Date- Tax Paid (S) / 
                                                                                                                                                                           Invoice Amt           Invoice Sales              Tax        Tax Payment  Tax Remitted (U)        Use Tax                                                                                                                        Legal 
                                                                                                               Item Description (as               Total Invoice           Before Sales               Tax Pd.            Type  (S Method (check,                   mo/day/yr                       Pd.                                                                 Factual Basis for             Basis/Authority            Additional 
                      Vendor Name                           Invoice No.               Invoice Date             detailed on invoice)                   Amount                     Tax                 Amount                or U)             EFT)               (Also see Sec. IV)             Amount              STATE           PHILA.          ALLEGH.                   Refund                     (if known)            Comments               T/E      STATE           PHILA.         ALLEGH. COMMENTS
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          (Insert lines above as appropriate. Do not alter columns A-Z. Add columns to Section IV only)                                                                                                                                                                                                                                                                                                                                                              -              -               -   
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          * Copies of Invoices and/or receipts must be provided                                                                                                                                                          * Copies of cancelled checks, bank statements, 
                                                                                                                                                                                                                        receipt or other payment remittance confirmation 
                                                                                                                                                                                                                           and use tax accrual records must be provided
                               SECTION IV ADDITIONAL INFORMATION (AS APPLICABLE)
                 DOCUMENTATION HYPERLINKS                             ACCOUNTING INFORMATION
                           PROOF OF          ADD'L                                                        PERIOD 
              INVOICE      PAYMENT        INFORMATION     LOCATION/     COST                  GL ACCT     USE TAX 
             HYPERLINK    HYPERLINK        HYPERLINK       DIVISION    CENTER    GL ACCT #     NAME      ACCRUED
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