Form 911 - Request For Taxpayer Advocate Service Assistance - Department Of The Treasury - 2015
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4Department of the Treasury - Internal Revenue Service
911
OMB Number
Form
Request for Taxpayer Advocate Service Assistance
1545-1504
(February 2015)
(And Application for Taxpayer Assistance Order)
Section I – Taxpayer Information
(See Pages 3 and 4 for Form 911 Filing Requirements and Instructions for Completing this Form.)
1a. Your name as shown on tax return
1b. Taxpayer Identifying Number (SSN, ITIN, EIN)
2a. Spouse's name as shown on tax return (if applicable)
2b. Spouse's Taxpayer Identifying Number (SSN, ITIN)
3a. Your current street address (Number, Street, & Apt. Number)
3b. City
3c. State (or Foreign Country)
3d. ZIP code
4. Fax number (if applicable)
5. Email address
6. Tax form number (1040, 941, 720, etc.)
7. Tax year(s) or period(s)
9b.
8. Person to contact if Section II is not being used
9a. Daytime phone number
Check here if you consent to
have confidential information
about your tax issue left on your
10. Best time to call
answering machine or voice
Check if Cell Phone
message at this number.
11. Preferred language (if applicable)
TTY/TDD Line
Interpreter needed - Specify language other than English (including sign language)
Other (please specify)
12a. Please describe the tax issue you are experiencing and any difficulties it may be creating
(If more space is needed, attach additional sheets.) (See instructions for completing Lines 12a and 12b)
12b. Please describe the relief/assistance you are requesting (If more space is needed, attach additional sheets.)
I understand that Taxpayer Advocate Service employees may contact third parties in order to respond to this request and I authorize
such contacts to be made. Further, by authorizing the Taxpayer Advocate Service to contact third parties, I understand that I will not
receive notice, pursuant to section 7602(c) of the Internal Revenue Code, of third parties contacted in connection with this request.
13a. Signature of Taxpayer or Corporate Officer, and title, if applicable
13b. Date signed
14a. Signature of spouse
14b. Date signed
Section II – Representative Information
(Attach Form 2848 if not already on file with the IRS.)
1. Name of authorized representative
2. Centralized Authorization File (CAF) number
3. Current mailing address
4. Daytime phone number
Check if
Cell Phone
5. Fax number
6. Signature of representative
7. Date signed
911
Catalog Number 16965S
Form
(Rev. 2-2015)
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Parent category: Financial