Tax Offset Appeal form v1 - Ivy Tech Community College of ...

IVY TECH COMMUNITY COLLEGE

Tax Offset Appeal Form

Our records indicate that you owe a balance to the College. Indiana Code 6-8.1-9.5 authorizes Ivy Tech Community College as a Claimant Agency to report the debt to the Indiana Department of Revenue for possible offset from a future Indiana income tax refund due to you. As such the Department of Revenue Services will garnish (intercept) your State of Indiana income tax return on behalf of Ivy Tech Community College in order to pay the outstanding balance.

If you feel this debt is not valid, you have the right to request a hearing via an appeal process with Ivy Tech. Your written appeal (below) and documentation must be received at Ivy Tech Community College within 30 days of the date of your notification letter. Failure to provide a written request for a hearing or proof of prior payment will constitute acknowledgement of the debt owed. If you have any questions, please call us at 1-888-489-5463.

PLEASE PRINT

Student Name ______________________________________________________________________________________

First

Middle

Last

Telephone (_____)__________________ Date of Birth_______________ Student ID # C________________________

Current Street Address __________________________________________ Last 4 digits of SSN xxx-xx-_____________

City ________________________________________ State ________________________ Zip Code ________________

Campus Attended__________________________ E-Mail Address____________________________________________

In the space below, please describe why the outstanding balance is inaccurate. ATTACH DOCUMENTATION SUBSTANTIATING ANY INACCURACY.

__________________________________________________________________________ Student Signature

_______________________________________ Date

Send completed form and documentation to:

Ivy Tech Community College ATTN: Tax Appeal Review Board 50 W. Fall Creek Parkway N. Dr.

Indianapolis, IN 46208

Office Use Only

Tax Offset Letter Date ______________________ Appeal Received Date:___________________________

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