Form 13711 - Request For Appeal Of Offer In Compromise
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1Request for Appeal of Offer in Compromise
Please provide the information required in the spaces below. Be sure to sign and date this form.
Taxpayer name(s)
Taxpayer Identification Number(s)
Taxpayer name(s)
Taxpayer Identification Number(s)
Mailing address
Tax form number
City
State
ZIP Code
Tax period(s) ended
Taxpayer's current daytime phone number
Tax period(s) ended
Identify the specific item(s) you don't agree with as shown on the Income and Expense Table and Asset and Equity Table you received with
your rejection letter. In the space next to the disagreed item, provide a brief statement indicating why you don't agree with our determination
(for example: incorrect valuation of real estate, omitted mileage from vehicle deduction, etc.). Attach supporting documents and indicate on
the document which issue they apply to. Additional pages may be attached. If you do not agree with the Service's analysis of economic
hardship or Effective Tax Administration, please provide an explanation with documentation.
Disagreed item
Reason for disagreement
Supporting documentation attached
Yes
No
Disagreed item
Reason for disagreement
Supporting documentation attached
Yes
No
Disagreed item
Reason for disagreement
Supporting documentation attached
Yes
No
Signature of Taxpayer(s)
Date signed
Signature of Taxpayer(s)
Date signed
If this application was prepared by someone other than the taxpayer, please fill in that person's name and address
Name
Mailing address
City
State
ZIP Code
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 of authorized representative
Signature of authorized representative
Date signed
Telephone number of authorized representative
Best time to call
13711
Cat. No. 40992F
Department of the Treasury - Internal Revenue Service
Form
(Rev. 6-2009)
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