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Form 8546 - Claim For Reimbursement Of Bank Charges Incurred Due To Erroneous Service Levy Or Misplaced Payment Check

Department of the Treasury - Internal Revenue Service

8546

Form

Claim for Reimbursement of Bank Charges Incurred Due to

(Rev. February 2001)

Erroneous Service Levy or Misplaced Payment Check

Instructions

Prepare this form in ink or use a typewriter. Please carefully read the instructions on the back of this form and supply the

information requested. Use additional sheet

if necessary. Submit this form to the address of the IRS office which served

(s)

the levy or the address of the office that misplaced the payment.

1. Name and address of claimant

2. Telephone number

(Number, street, city, state, and ZIP code)

(including area code)

3. Best time

4. Amount of claim

to call

5. Social security or employer identification number

(Disclosure is voluntary. Omission may delay your claim or

prevent locating your records.)

Electronic Funds Transfer

Information

(EFT)

(See instructions on the back of this form.)

6. Name

on bank account

7. American Bankers Association

number

(s)

(ABA)

8. Bank name and address

9. Bank account number

(Number, street, city, state, ZIP code)

10. Type of account

Checking

Savings

11. Description of claim

(State the circumstances which resulted in the loss for which you are claiming reimbursement.)

I certify that the amount of my claim covers only bank charges which resulted from either

an erroneous I.R.S. levy or having to stop payment on a check which was lost or misplaced

Certification

by the I.R.S. I agree to accept this amount in full satisfaction and final settlement of this

incident.

12. Signature of claimant

13. Date of claim

(This signature should be used in all future correspondence.)

Civil Penalty for Presenting

Fraudulent Claim

Fraudulent Claim or Making False Statements

The claimant shall be liable to the United States for the sum of

Fine of not more than $10,000 or imprisonment for not more

$2,000 plus double the amount of damages sustained by the

than 5 years or both.

(See 62 Stat. 698, 749; 18 USC 287, 1001.)

United States.

(See R S § 3490, 5438, 31 USC 3729.)

8546

Catalog Number 63488O

Form

(Rev. 2-2001)

Form 8546 - Claim For Reimbursement Of Bank Charges Incurred Due To Erroneous Service Levy Or Misplaced Payment Check

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