Form 12509 - Statement Of Disagreement

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12509
Form
Statement of Disagreement
(January 2005)
Purpose of form: You can use this form to explain why you disagree with the Internal Revenue Service (IRS)
Determination concerning relief from joint and several liability for a joint return under Internal Revenue Code sections
6013(e), 6015(b), 6015(c), or 6015(f) in the letter you received with this form.
Note: You can use the back of this page or attached additional pages if you need more space.
CHECK HERE IF YOU ALSO WISH TO GO TO APPEALS
Taxpayer Name:
Social Security Number
Statement of Disagreement
I,
, disagree with the Internal Revenue Service determination because
Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is
true, correct and complete.
My Signature
Date
Daytime phone number
Best time to Call
12509
Form
(Rev. 1-2005)
Catalog Number 28731A
Department of the Treasury-Internal Revenue Service

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Parent category: Financial
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