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
Claim for Reimbursement of Bank Charges Incurred Due to
(Rev. February 2001)
Erroneous Service Levy or Misplaced Payment Check
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
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
(See instructions on the back of this form.)
6. Name
on bank account
7. American Bankers Association
8. Bank name and address
9. Bank account number
(Number, street, city, state, ZIP code)
10. Type of account
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
by the I.R.S. I agree to accept this amount in full satisfaction and final settlement of this
12. Signature of claimant
13. Date of claim
(This signature should be used in all future correspondence.)
Civil Penalty for Presenting
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.)
Catalog Number 63488O
(Rev. 2-2001)


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