Form 12203 - Request For Appeals Review
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1
2Request for Appeals Review
Please complete the information in the spaces below, including your signature and the date.
Taxpayer name(s)
Taxpayer Identification Number(s)
Mailing address
Tax form number
City
Tax period(s) ended
State
ZIP Code
Identify the item(s) (for example: filing status, exemptions, interest or dividends) you disagree with in the proposed change or assessment report you
received with the enclosed letter. Tell us why you disagree. You can add more pages if this is not enough space.
Disagreed item
Reason why you disagree
Disagreed item
Reason why you disagree
Disagreed item
Reason why you disagree
Disagreed item
Reason why you disagree
Signature of Taxpayer(s)
Date
Date
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
Signature
Date
Your telephone number
Best time to call
12203
Cat. No. 27136N
Department of the Treasury - Internal Revenue Service
Form
(Rev. 4-2004)
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Parent category: Financial