(account number)
(address line two)
(address one)
(CLEAR) CLEAR
(DATE OF NOTICE BILLING OR REFUND CLAIM)
(date of notice)
(day time phone number)
(dollar amount)
(firm name)
(MONTH/DAY/YEAR)
(period month day year)
(print and clear buttons) PRINT
(reason)
(taxpayer/feepayer)
(through month day year)
(title)
(todays date)
** The person signing this form if not a corporate officer partner or owner certifies under penalty of perjury that he or she holds a power of
Account No(s) :
Address:
and the Occupational Lead Poisoning Prevention Fee disputes involving the Hazardous Substances Tax Law
are administered by the Department of Toxic Substances Control Please submit the Settlement Proposal to:
attorney to execute this document as evidenced by the attached Power of Attorney form
be considered
Board of Equalization s (BOE) Settlement Section staff will be submitted to the BOE s executive management
BOE 393 REV 3 (12 10)
DAYTIME TELEPHONE NUMBER
FIRM NAMEDate:
for approval
for settlement as follows:
for the
I believe this settlement offer is reasonable because:
I request that the tax or fee amount in question for the above account(s) established on
I understand that all settlement offers are subject to review and that only those considered reasonable by the
NOTE:
period(s)
PO Box 942879; Sacramento CA 94279 0087
Proposed Settlement Amount $
SALES AND USE TAX AND SPECIAL TAXES AND FEE CASES
SETTLEMENT PROPOSAL FOR:
SIGNATURE
State Board of Equalization; Assistant Chief Counsel Settlement & Taxpayer Services Division MIC:87;
STATE OF CALIFORNIABOARD OF EQUALIZATION
tax disputes Also with the exception of disputes pertaining to the Childhood Lead Poisoning Prevention Fee
Taxpayer/Feepayer:
The settlement program does not currently apply to motor vehicle fuel license tax disputes or to insurance
through
TITLE
