Request for a Collection Due Process or Equivalent Hearing
Use this form to request a Collection Due Process (CDP) or equivalent hearing with the IRS Office of
Appeals if you have been issued one of the following lien or levy notices:
•
Notice of Federal Tax Lien Filing and Your Right to a Hearing under IRC 6320,
•
Notice of Intent to Levy and Notice of Your Right to a Hearing,
•
Notice of Jeopardy Levy and Right of Appeal,
•
Notice of Levy on Your State Tax Refund,
•
Notice of Levy and Notice of Your Right to a Hearing.
Complete this form and send it to the address shown on your lien or levy notice. Include a
copy of your lien or levy notice to ensure proper handling of your request.
Call the phone number on the notice or 1-800-829-1040 if you are not sure about the correct address
or if you want to fax your request.
You can find a section explaining the deadline for requesting a Collection Due Process
hearing in this form's instructions. If you've missed the deadline for requesting a CDP
hearing, you must check line 6 (Equivalent Hearing) to request an equivalent hearing.
1. Taxpayer Name: (Taxpayer 1)
Taxpayer Identification Number
Current Address
City
Zip Code
State
-
(
)
2.
Home
am.
pm.
Telephone Number and Best Time
to Call During Normal Business
(
)
-
Work
am.
pm.
Hours
(
)
Cell
am.
pm.
3. Taxpayer Name: (Taxpayer 2)
Taxpayer Identification Number
Current Address
(If Different from
City
Zip Code
State
Address Above)
-
am.
pm.
4.
(
)
Home
Telephone Number and Best Time
to Call During Normal Business
(
)
-
Work
am.
pm.
Hours
(
)
-
am.
pm.
Cell
5. Tax Information as Shown on the Lien or Levy Notice (
)
If possible, attach a copy of the notice
Type of Tax (Income,
Tax Form Number
Tax Period or Periods
Employment, Excise,
(1040, 941, 720, etc)
etc. or Civil Penalty)
12153
Form
(Rev. 3-2011)
Catalog Number 26685D
Department of the Treasury - Internal Revenue Service