Fillable Form 9423 - Collection Appeal Request printable pdf download

Form 9423 - Collection Appeal Request

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Collection Appeal Request

(Instructions are on the reverse side of this form)

1. Taxpayer’s name

2. Representative (Attach a copy of Form 2848, Power of Attorney)

3. SSN/EIN

4. Taxpayer’s business phone

5. Taxpayer’s home phone

6. Representative’s phone

7. Taxpayer’s street address

8. City

9. State

10. ZIP code

11. Type of tax (Tax form)

12. Tax periods being appealed

13. Tax due

Collection Action(s) Appealed

14. Check the Collection action(s) you are appealing

Federal Tax Lien

Levy or Proposed Levy

Seizure

Rejection of Installment Agreement

Termination of Installment Agreement

Modification of Installment Agreement

Explanation

15. Explain why you disagree with the collection action(s) you checked above and explain how you would resolve your tax problem.

Attach additional pages if needed. Attach copies of any documents that you think will support your position.

Under penalties of perjury, I declare that I have examined this request and the attached documents, and to the best of my knowledge and belief, they are

true, correct and complete. A submission by a representative, other than the taxpayer, is based on all information of which preparer has any knowledge.

16.

Taxpayer’s or

Authorized Representative’s signature (Only check one box)

17. Date signed

IRS USE ONLY

18. Revenue Officer's name

19. Revenue Officer's signature

20. Date signed

21. Revenue Officer's phone

22. Revenue Officer's FAX

23. Date received

24. Collection Manager’s name