Form 12203-A - Request For Appeal

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Department of the Treasury - Internal Revenue Service
12203-A
Form
Request for Appeal
(September 2015)
You must complete the information in the spaces below, including your signature(s) and the date.
Continuing Education Provider name
Program name
Program number(s)
Year of review
Mailing address
City
State
ZIP code
Identify the item(s) that you disagree with on Letter 4890 Notice of Denial or on the Summary of Findings Report that you received with
the Letter 5015 Notice of Revocation. Tell us why you disagree. You can add more pages if this is not enough space. Please refer to
the appropriate
Continuing Education Provider Standards
in your remarks.
CE Provider standard number
Reason why you disagree
CE Provider standard number
Reason why you disagree
CE Provider standard number
Reason why you disagree
CE Provider standard number
Reason why you disagree
Signature(s) of Designated Official for Provider
Name
Signature
Date
Name
Signature
Date
Name and signature of authorized representative (If a representative is signing this form, please attach a copy of your completed
Form 2848, Power of Attorney and Declaration of Representative.)
Name
Signature
Date
Your telephone number
Best time to call
12203-A
Catalog Number 68271P
Form
(9-2015)

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