Form 12175 - Third Party Contact Report Form - Department Of The Treasury

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Third Party Contact Report Form
2. Name Control
1. Taxpayer TIN
3. Employee ID Number
(Include appropriate file source code.)
Employee Telephone Number
4. Secondary TIN
(Joint filing 1040 only.)
Employee Mail Stop Number
5. Third Party Contact is for:
(Please check one.)
Both
Primary TIN
Secondary TIN
(Note: Check both for joint filing 1040 only.)
Contact Information
6. Date of Contact:
/
/
(Date format is: yyyy/mm/dd.)
7. Reprisal Determination
If fear of reprisal has been indicated, check the box below
8. Name of Third Party
(only one 3rd party contact per form.)
8a. Check the one category that best describes the third party.
1. Individual
3. Business
4. State/Fed. Government Org.
5. Other
2. Financial Institution
9. TE/GE Use Only
TE/GE Determination (EDS) Case Number or
National Office Case Control Number
EP Plan Number
10. MFT/TAX Period
(Enter all MFT tax periods relating to Primary TIN)
Example: 30
1999
12
MFT
Year
Month
This area is for Third Party Coordinator document control tracking use only. Enter Document Sequence Number.
Document Sequence Number:
Department of the Treasury - Internal Revenue Service
Form 12175 (Rev. 02/2001)
Cat. No. 26796L

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