6118
Claim for Refund of Tax Return
Form
Preparer and Promoter Penalties
OMB No. 1545-0240
(Rev. August 2009)
For Penalties Assessed Under IRC Sections 6694, 6695, 6700, and 6701.
Department of the Treasury
See instructions on page 2.
Internal Revenue Service
Name of preparer or promoter
Identifying number
See instructions.
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.
A
Understatements due to unreasonable positions—section 6694(a)
G Failure to file a record of return preparers—section 6695(e)(1)
B
Willful or reckless conduct (intentional disregard of rules and
H Failure to include an item in the required record of return
regulations)—section 6694(b)
preparers—section 6695(e)(2)
I Negotiation of check—section 6695(f)
C
Failure to furnish copy of return or claim for refund to taxpayer—
J Failure to exercise due diligence in determining eligibility for,
section 6695(a)
and/or amount of, the earned income credit—section 6695(g)
D
Failure to sign return or claim for refund—section 6695(b)
K Promoting abusive tax shelters, etc.—section 6700
E
Failure to furnish identifying number—section 6695(c)
L
Aiding and abetting understatement of tax liability—section 6701
F
Failure to retain copy or list—section 6695(d)
M Other (specify) (see instructions)
Identification of Penalties. Enter the information from your statement.
(a)
(b)
(c)
(d)
Statement document
Date of
Type of
Name(s) of taxpayer(s)
locator number (DLN)
statement
penalty
1
2
3
4
5
6
7
8
9
10
11
12
(e)
(f)
(g)
(h)
(i)
(j)
Taxpayer’s identification
Form
Tax
Amount
Amount
Date paid
number
number
year
assessed
paid
(mo., day, yr.)
1
2
3
4
5
6
7
8
9
10
11
12
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.
Sign
Here
Signature
Date
6118
For Privacy Act and Paperwork Reduction Act Notice, see back of form.
Cat. No. 24415J
Form
(Rev. 8-2009)