Penalty Waiver Request
78-629a (06/10/19)
Check appropriate box for type of tax. Other tax types include Cigarette/Tobacco, Consumer’s Use,
Fiduciary, Franchise, Fuel, Inheritance, and Generation Skipping Transfer:
Sales Individual Income Corporation Income
Retailer’s Use Withholding Other : ____________________________
Taxpayer/Business name: _____________________________________________________________
Address: __________________________________________________________________________
City: ______________________________________________ State: _________ ZIP: ____________
Permit/SSN/FEIN: _________________________ Account number (if billed): ____________________
Tax period(s): ______________________________________________________________________
1. Select Reason(s) for Waiver Number from the list on pg. 2: # __________
2. Attach documentation to support your waiver request. Supporting documentation must be
included for reasons number 3 through 13.
3. Describe below why the penalty waiver reason(s) you selected applies.
I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this
request, and, to the best of my knowledge and belief, it is true, correct, and complete.
Signature: ________________________________ Contact name: ____________________________
Phone number: _____________________________________________________________________
eMail: _______________________________________________ Date: _______________________
Submit Waiver Request
Fax: 515-281-0763
Mail to: Iowa Department of Revenue Penalty Waiver
PO Box 10471
Des Moines, IA 50306-0471
Instructions for Penalty Waiver Request, page 2
78-629b (01/30/19)
Permit/SSN/FEIN: Enter the permit number, Social Security Number, or Federal Employer
Identification Number for which penalty waiver is requested.
Account number: If you have been billed, enter the account number shown on the billing notice.
Reason(s) for Waiver Number: From the list of 13 penalty waiver reasons shown below, enter the
number(s) of the waiver reason(s) applicable to your situation. Reasons 3 through 13 require
supporting documentation.
Taxpayer timely pays at least 90% of the correct tax due: A, B, C
Taxpayer files a late return or deposit form but has 36 immediately prior months of timely filing
history (semi-monthly, monthly & quarterly filers only) (not applicable to income tax, corporate
tax, or franchise tax): A
Taxpayer, immediate family member, or responsible party dies: A (Additional requirements
Taxpayer, immediate family member, or responsible party becomes seriously ill or hospitalized:
A (Additional requirements apply.)
Taxpayer’s records are destroyed by fire, flood, or other act of nature: A
Taxpayer proves he or she relied on case-specific written advice from the Department of
Revenue, Department of Transportation, county treasurer, or IRS: A, B, C
Taxpayer shows he/she relied on results of a previous audit: A, B, C
Taxpayer provides documented proof of substantial authority to support his/her particular
position and that all facts and circumstances were disclosed on the return or deposit: A, B, C
Taxpayer provides proof that the return, deposit form, or payment was mailed on time and with
proper postage but that it was incorrectly mailed to the IRS or other state or local governmental
agency: A, B
Taxpayer proves before being contacted by the Department that the wrong permit holder paid
the tax timely: A, B
Taxpayer discovers through the Department’s self-audit program* that he/she failed to file: A
Taxpayer voluntarily files an amended return and pays all tax due before being contacted by the
Department except under a Department self-audit program*: B
Taxpayer voluntarily provides written proof of a federal audit and files a return with payment
within 60 days of completion of the federal audit: B
Penalty Type A 10% Penalty for Failure to Timely File a Return
Penalty Type B 5% Penalty for Failure to Timely Pay the Tax Due
Penalty Type C 5% Penalty for Audit Deficiencies
NOTE: The 75% Penalty for Willful Failure to File a Return cannot be waived.
* A taxpayer involved with a self-audit program will receive a letter from the Department that will
identify the audit as a self-audit program. The specific years will be identified. Any returns voluntarily
filed that are not part of the self-audit program do not qualify for a waiver of penalty for this reason.
Documentation: Attach additional documentation to support your reason(s) for requesting a penalty
waiver. Your request will be DENIED, if supporting documentation is not provided for reasons number
3 through 13.