Form 12661 - Disputed Issue Verification
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1Department of the Treasury - Internal Revenue Service
12661
Form
Disputed Issue Verification
(October 2015)
Taxpayer name
Tax period
Social Security Number
Instructions for completing disputed issues
Please complete a separate block for each issue or adjustment with which you disagree.
Attach photocopies of supporting information for each issue or adjustment marked. Number the supporting information with the same
number as its disputed issue. If you need additional blocks, photocopy additional sheets and number accordingly.
1. Disputed issue or adjustment
Reason why you disagree with the audit results
Amount claimed on original return
Amounts allowed on Audit report
2. Disputed issue or adjustment
Reason why you disagree with the audit results
Amount claimed on original return
Amounts allowed on Audit report
3. Disputed issue or adjustment
Reason why you disagree with the audit results
Amount claimed on original return
Amounts allowed on Audit report
Do not send original documents — Send photocopies only
For Privacy Act Notice see the instructions for your return.
12661
Catalog Number 29360J
Form
(Rev. 10-2015)
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Parent category: Financial