Form 4810 - Request For Prompt Assessment Under Ir Code Section 6501(D)
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24810
Request for Prompt Assessment Under
OMB No. 1545-0430
Form
Internal Revenue Code Section 6501(d)
(Rev. February 2009)
Department of the Treasury
For IRS Use Only
See instructions on back.
Internal Revenue Service
Requester’s name
Kind of tax
Income
Gift
Title
Employment
Excise
Number, street, and room or suite no. (If a P.O. box, see instructions.)
Daytime phone number
City, town, or post office, state, and ZIP code
Tax Returns for Which Prompt Assessment of Any Additional Tax is Requested
Form
Tax Period
SSN/EIN on
Name and Address Shown on Return
Service Center Where Filed
Date Filed
Number
Ended
Return
If applicable, provide the name of decedent’s spouse (surviving or deceased)
Spouse’s social security number
If corporate income tax returns are included, check the applicable box below:
Dissolution has been completed.
Dissolution has begun and will be completed either before or after the 18-month period of limitation.
Dissolution has not begun but will begin before the 18-month period of limitation expires and will be completed either before or after
that period expires.
Attached are copies of:
The returns listed above.
Letters of administration or letters testamentary.
Other (describe):
I request a prompt assessment of any additional tax for the kind of tax and periods shown above, as provided by Internal Revenue Code
section 6501(d).
Under penalties of perjury, I declare that I have examined this request, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
Sign
I certify that I have never been assessed any penalties for civil fraud for any federal or state tax matter nor have I been charged with,
indicted for, or convicted of fraud. If you cannot certify this statement, attach a detailed statement explaining the circumstances under
Here
which you were assessed a penalty, charged with, indicted for, or convicted of fraud.
Signature of requester
Date
Identifying number
4810
For Privacy Act and Paperwork Reduction Act Notice, see back of form.
Cat. No. 42022S
Form
(Rev. 2-2009)
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