Claim for Refund of Tax Return
Preparer and Promoter Penalties
OMB No. 1545-0240
(Rev. April 2017)
For Penalties Assessed Under IRC Sections 6694, 6695, 6700, and 6701.
Department of the Treasury
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Internal Revenue Service
Name of preparer or promoter
Address to which statement(s) of notice and demand were mailed
City, town or post office, state, and ZIP code
IRS office that sent statement(s)
Address of preparer shown on return(s) for which penalties were assessed (if different from above)
Type of Penalty. Enter letter in column (c) below.
Understatements due to unreasonable positions—section 6694(a)
Failure to include an item in the required record of return
Willful or reckless conduct (intentional disregard of rules and
Negotiation of check—section 6695(f)
Failure to furnish copy of return or claim for refund to taxpayer—
Failure to exercise due diligence in determining eligibility for, and/or
amount of, the earned income credit, child tax credit, additional child tax
credit, and/or American Opportunity tax credit—section 6695(g)
Failure to sign return or claim for refund—section 6695(b)
Failure to furnish identifying number—section 6695(c)
Promoting abusive tax shelters, etc.—section 6700
Failure to retain copy or list—section 6695(d)
Aiding and abetting understatement of tax liability—section 6701
G Failure to file a record of return preparers—section 6695(e)(1)
M Other (specify) (see instructions)
Identification of Penalties. Enter the information from your statement.
Name(s) of taxpayer(s)
locator number (DLN)
(mo., day, yr.)
Amount of Claim. Enter the total of column (i), lines 1 through 12 . . . . . .
Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete.
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Cat. No. 24415J