Request For A Collection Due Process Or Equivalent Hearing Page 2
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1
212153
Form
Request for a Collection Due Process or Equivalent Hearing
(Rev. 12-2013)
6. Basis for Hearing Request (Both boxes can be checked if you have received both a lien
and levy notice)
Filed Notice of Federal Tax Lien
Proposed Levy or Actual Levy
7. Equivalent Hearing (See the instructions for more information on Equivalent Hearings)
I would like an Equivalent Hearing - I would like a hearing equivalent to a CDP Hearing if my
request for a CDP hearing does not meet the requirements for a timely CDP Hearing.
8. Check the most appropriate box for the reason you disagree with the filing of the lien or the levy.
See page 4 of this form for examples. You can add more pages if you don't have enough space.
If, during your CDP Hearing, you think you would like to discuss a Collection Alternative to the
action proposed by the Collection function it is recommended you submit a completed Form
433A (Individual) and/or Form 433B (Business), as appropriate, with this form. See
for copies of the forms. Generally, the Office of Appeals will ask the Collection Function to
review, verify and provide their opinion on any new information you submit. We will share their
comments with you and give you the opportunity to respond.
Collection Alternative
Installment Agreement
Offer in Compromise
I Cannot Pay Balance
Lien
Subordination
Discharge
Withdrawal
Please explain:
My Spouse Is Responsible
Innocent Spouse Relief (Please attach Form 8857,
Request for Innocent Spouse Relief, to your request.)
Other (
)
For examples, see page 4
Reason (
You must provide a reason for the dispute or your request for a CDP hearing will not be honored. Use as
):
much space as you need to explain the reason for your request. Attach extra pages if necessary.
9. Signatures
I understand the CDP hearing and any subsequent judicial review will suspend the statutory
period of limitations for collection action. I also understand my representative or I must sign and
date this request before the IRS Office of Appeals can accept it. If you are signing as an officer of
a company add your title (
) behind your signature.
president, secretary, etc.
SIGN HERE
Taxpayer 1's Signature
Date
Taxpayer 2's Signature (
)
Date
if a joint request, both must sign
I request my CDP hearing be held with my authorized representative (
attach a copy of Form
)
2848
Authorized Representative's Signature
Authorized Representative's Name
Telephone Number
IRS Use Only
IRS Employee (Print)
Employee Telephone Number
IRS Received Date
12153
Form
(Rev. 12-2013)
Catalog Number 26685D
Department of the Treasury - Internal Revenue Service
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