Form 12203 - Request For Appeals Review
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1
2Department of the Treasury - Internal Revenue Service
12203
Form
Request for Appeals Review
(February 2016)
Complete the information in the spaces below, including your signature and the date.
Taxpayer name(s)
Taxpayer Identification Number(s)
Mailing address
Tax form number
City
Tax period(s) ended
State
ZIP Code
Your telephone number(s)
Best time to call
Identify the item(s)
you disagree with in the proposed change or assessment
(for example: filing status, exemptions, interest or dividends)
report you received with the enclosed letter. Tell us why you disagree. You can add more pages if this is not enough space.
Disagreed item
Reason why you disagree
Disagreed item
Reason why you disagree
Disagreed item
Reason why you disagree
Disagreed item
Reason why you disagree
Name of Taxpayer
Date
Signature
Name of Taxpayer
Date
Signature
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
Date
Signature
Your telephone number
Best time to call
12203
Catalog Number 27136N
Form
(Rev. 2-2016)
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Parent category: Financial