Form 12153 - Request For A Collection Due Process Or Equivalent Hearing Page 2
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4Request for a Collection Due Process or Equivalent Hearing
6.
Basis for Hearing Request (Both boxes can be checked if you have received both a lien
and levy notice)
Filed Notice of Federal Tax Lien
Proposed Levy or Actual Levy
7. Equivalent Hearing (See the instructions for more information on Equivalent Hearings)
I would like an Equivalent Hearing - I would like a hearing equivalent to a CDP Hearing if my
request for a CDP hearing does not meet the requirements for a timely CDP Hearing.
8. Check the most appropriate box for the reason you disagree with the filing of the lien or the levy.
See page 4 of this form for examples. You can add more pages if you don't have enough space.
If, during your CDP Hearing, you think you would like to discuss a Collection Alternative to the
action proposed by the Collection function it is recommended you submit a completed Form
433A (Individual) and/or Form 433B (Business), as appropriate, with this form. See
for copies of the forms.
Collection Alternative
Installment Agreement
Offer in Compromise
I Cannot Pay Balance
Subordination
Discharge
Withdrawal
Lien
Please explain:
My Spouse Is Responsible
Innocent Spouse Relief (Please attach Form 8857,
Request for Innocent Spouse Relief, to your request.)
Other (
)
For examples, see page 4
Reason (
You must provide a reason for the dispute or your request for a CDP hearing will not be honored. Use as
):
much space as you need to explain the reason for your request. Attach extra pages if necessary.
I understand the CDP hearing and any subsequent judicial review will suspend the statutory
9. Signatures
period of limitations for collection action. I also understand my representative or I must sign and
date this request before the IRS Office of Appeals can accept it. If you are signing as an officer
of a company add your title (
) behind your signature.
president, secretary, etc.
SIGN HERE
Taxpayer 1's Signature
Date
Taxpayer 2's Signature (
)
Date
if a joint request, both must sign
I request my CDP hearing be held with my authorized representative (
attach a copy of Form
)
2848
Authorized Representative's Signature
Authorized Representative's Name
Telephone Number
IRS Use Only
IRS Employee (Print)
Employee Telephone Number
IRS Received Date
12153
Form
(Rev. 3-2011)
Catalog Number 26685D
Department of the Treasury - Internal Revenue Service
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