Form 911 - Request For Taxpayer Advocate Service Assistance

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OMB No. 1545-1504
Department of the Treasury - Internal Revenue Service
Request for Taxpayer Advocate Service Assistance
(Rev. 5-2011)
(And Application for Taxpayer Assistance Order)
Section I – Taxpayer Information
(See Pages 3 and 4 for Form 911 Filing Requirements and Instructions for Completing this Form.)
1a. Your name as shown on tax return
1b. Taxpayer Identifying Number (SSN, ITIN, EIN)
2a. Spouse's name as shown on tax return (if applicable)
2b. Spouse's Taxpayer Identifying Number (SSN, ITIN)
3a. Your current street address (Number, Street, & Apt. Number)
3b. City
3c. State (or Foreign Country)
3d. ZIP code
4. Fax number (if applicable)
5. Email address
6. Tax form(s)
7. Tax period(s)
8. Person to contact
9a. Daytime phone number
Check here if you consent to
have confidential information
about your tax issue left on your
10. Best time to call
answering machine or voice
Check if Cell Phone
message at this number.
11. Indicate the special communication needs you require (if applicable)
Interpreter - Specify language other than English (including sign language)
Other (please specify)
12a. Please describe the tax issue you are experiencing and any difficulties it may be creating
(If more space is needed, attach additional sheets.)
12b. Please describe the relief/assistance you are requesting (If more space is needed, attach additional sheets.)
I understand that Taxpayer Advocate Service employees may contact third parties in order to respond to this request and I authorize
such contacts to be made. Further, by authorizing the Taxpayer Advocate Service to contact third parties, I understand that I will not
receive notice, pursuant to section 7602(c) of the Internal Revenue Code, of third parties contacted in connection with this request.
13a. Signature of Taxpayer or Corporate Officer, and title, if applicable
13b. Date signed
14a. Signature of spouse
14b. Date signed
Section II – Representative Information
(Attach Form 2848 if not already on file with the IRS.)
1. Name of authorized representative
2. Centralized Authorization File (CAF) number
3. Current mailing address
4. Daytime phone number
Check if
Cell Phone
5. Fax number
6. Signature of representative
7. Date signed
Catalog Number 16965S
(Rev. 5-2011)


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