Free LT-E-031TaxAppealSmClaim - Hawaii

In The Tax Appeal Court of the State of Hawai`i
Small Claims Division In the Matter of the Tax Appeal ) Case No. _________________ ) of ) ) ) ) ) ) Appellant(s) ) ____________________________________ )

NOTICE OF APPEAL TO TAX APPEAL COURT

FROM _____________________________ OF THE ______________ TAXATION DISTRICT
Board of Review/Assessor

Taxation District Pursuant to Section 232-5, HRS, and the Small Claims Procedure of this Court

I
Appellant(s) name(s) ___________________________________________________________ (If corporation, indicate state of incorporation): Appellant(s) address: ___________________________________________________________ Appellant(s) Hawai`i general excise license number (if applicable):_______________________

II
Total amount of disputed tax liability excluding penalties and interest $ ___________________ , As determined by: _________________________________ . (Amount must be less than $1,000.)
Board of Review/Assessor

III
Nature of the tax: ______________________________________________________________ Year of period for which determination was made: ____________________________________

Reprographics (08/07)

LT-E-031

IV
Where real property tax is involved, furnishing the following information: a. Location (Tax Key No.): ______________________________________________ b. Land area: _________________________________________________________ c. Assessed single valuation for the year 20 ____ :
Single Appellant's Value Single Assessor's Value Single Board of Review's Value (if applicable)

If more than 1 year involved, attach separate sheets if necessary.

V
Amount of general excise tax (if applicable): ________________________________________ Place a "X" in box if paid under protest:

VI
The basis of this appeal is as follows: (Make your statements clear and concise. For property tax, see Section 232-3, HRS. Attached separate sheet if necessary.) WHEREFORE, appellant(s) pray(s) that the court enters its judgment herein determining the amount of the assessment or refund due and ordering such other relief as the court shall deem necessary and proper. The appellant(s) does (do) hereby waive the right to appeal the decision of this court to the Supreme Court upon the filing of this Notice of Appeal unless the same is transferred to the regular procedure pursuant to the Rules of the Small Claims Procedure. DATED: at ___________________ , Hawai`i, this _______ day of _____________ , 20 ____ .

_________________________________ Appellant's or Counsel's Signature

_________________________________ Appellant's or Counsel's Signature

Amount of court costs paid: ($25.00 non-refundable filing fee for small claim in any one case)
In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodations for a disability, please contact the ADA Coordinator at the Tax Appeal Court at (808) 539-4777 or FAX (808) 539-4713, at least ten (10) working days prior to your hearing or appointment date. For other related matters please call (808) 539-4777.

CLEAR