Fillable Form 12203-A - Request For Appeal (Page 2 of 2) in pdf

Page 2

Purpose of this form: You can use this form to appeal a Letter 4890 Notice of Denial or a Letter 5015 Notice of Revocation of your

IRS-approved CE Provider status. You must complete this form in its entirety and attach all supporting information, explanations or

documents for the appeal to be considered valid.

Instructions: Upload the completed form through your secure email in your online CE provider account or mail it to the address on the

Letter 4890 or Letter 5015. The IRS must receive this form within 30 calendar days of the date of the denial or revocation letter. Once a

valid appeal is received, a determination will be made. You will receive a notice that your appeal has either been upheld or overturned.

If you received a Letter 5015 Notice of Revocation and take no action within 30 calendar days, you will be removed from the public

listing of IRS approved CE Providers and be prohibited from reinstatement as an approved IRS CE Provider for a period of two years

from the date of revocation. Your website should not indicate that you are an approved IRS CE provider nor advertise IRS approved

programs. Any outstanding PTIN records not uploaded must be submitted within 10 calendar days.

Privacy Act and Paperwork Reduction Notice

We ask for the information on this form to carry out the laws of the United States. We need it to ensure that continuing education providers are

complying with these laws. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless

the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may

become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Internal

Revenue Code section 6103. The time require to complete this form will vary depending on individual circumstances. The estimated average time is 15

minutes.

The primary purpose of this form is to report potential violations of the law by continuing education providers. We are requesting this information under

authority of 26 U.S.C. § 7801 and § 7803 and 31 U.S.C. § 330. Providing this information is voluntary, and failure to provide all or part of the information

will not affect you. Providing false or fraudulent information may subject you to penalties. We may disclose this information to the Department of Justice

to enforce the tax laws, both civil and criminal, and to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their

tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal

laws, and to federal law enforcement and intelligence agencies to combat terrorism.

12203-A

Catalog Number 68271P

Form

(9-2015)