Form 8546 - Claim For Reimbursement Of Bank Charges
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28546
Department of the Treasury – Internal Revenue Service
Form
Claim for Reimbursement of Bank Charges
(Rev. February 2013)
Instructions
Please carefully read the instructions on the back of this form and provide the information requested. Use additional
sheet(s) if necessary. Submit this form to the address of the IRS office which served the levy, the address of the office
that misplaced the payment or the address that you used to file your tax return for Direct Debit Installment Agreement
Request.
1. Name and address of claimants
2. Telephone number
(Number, street, city, state, and ZIP code)
(including area code)
3. Best time to call
4. Amount of claim
$
5. Social security or employer identification number
(Disclosure is voluntary. Omission may delay your claim
or prevent locating your records.)
Electronic Funds Transfer
Information
(EFT)
(See instructions on the back of this form.)
6. Name
on bank account
7. American Bankers Association
number
(s)
(ABA)
8. Bank name and address
9. Bank account number
(Number, street, city, state, ZIP code)
10. Type of account
Checking
Savings
11. Description of claim
(State the circumstances which resulted in the loss for which you are claiming reimbursement.)
I certify that the amount of my claim covers only bank charges which resulted from either an
erroneous IRS levy, processing error by the Service for a Direct Debit Installment
Certification
Agreement or having to stop payment on a check which was lost or misplaced by the IRS. I
agree to accept this amount in full satisfaction and final settlement of this incident.
12. Signature of claimants
13. Date of claim
(This signature should be used in all future correspondence.)
Civil Penalty for Presenting
Civil Penalty for Presenting
Fraudulent Claim
Fraudulent Claim or Making False Statements
The claimant shall be liable to the United States for the sum of
Fine of not more than $10,000 or imprisonment for not more
$2,000 plus double the amount of damages sustained by the
than 5 years or both.
(See 62 Stat. 698, 749; 18 USC 287, 1001.)
United States.
(See R S § 3490, 5438, 31 USC 3729.)
8546
Catalog Number 63488O
Form
(Rev. 2-2013)
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