Form 911 - Request For Taxpayer Advocate Service Assistance Page 2

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Section III – Initiating Employee Information
(Section III is to be completed by the IRS only)
Taxpayer name
Taxpayer Identifying Number (TIN)
1. Name of employee
2. Phone number
3a. Function
3b. Operating division
4. Organization code no.
6. IRS received date
5. How identified and received (Check the appropriate box)
IRS Function identified issue as meeting Taxpayer Advocate Service (TAS) criteria
(r) Functional referral (Function identified taxpayer issue as meeting TAS criteria).
(x) Congressional correspondence/inquiry not addressed to TAS but referred for TAS handling.
Name of Senator/Representative
Taxpayer or Representative requested TAS assistance
(n) Taxpayer or representative called into a National Taxpayer Advocate (NTA) Toll-Free site.
(s) Functional referral (taxpayer or representative specifically requested TAS assistance).
7. TAS criteria (Check the appropriate box. NOTE: Checkbox 9 is for TAS Use Only)
(1) The taxpayer is experiencing economic harm or is about to suffer economic harm.
(2) The taxpayer is facing an immediate threat of adverse action.
(3) The taxpayer will incur significant costs if relief is not granted (including fees for professional representation).
(4) The taxpayer will suffer irreparable injury or long-term adverse impact if relief is not granted.
(if any items 1-4 are checked, complete Question 9 below)
(5) The taxpayer has experienced a delay of more than 30 days to resolve a tax account problem.
(6) The taxpayer did not receive a response or resolution to their problem or inquiry by the date promised.
(7) A system or procedure has either failed to operate as intended, or failed to resolve the taxpayer's problem or dispute within
the IRS.
(8) The manner in which the tax laws are being administered raise considerations of equity, or have impaired or will impair the
taxpayer's rights.
(9) The NTA determines compelling public policy warrants assistance to an individual or group of taxpayers (TAS Use Only)
(This block MUST be completed by the initiating employee)
8. What action(s) did you take to help resolve the issue?
If you were unable to resolve the issue, state the reason why (if applicable)
9. Provide a description of the Taxpayer's situation, and where appropriate, explain the circumstances that are creating the economic
burden and how the Taxpayer could be adversely affected if the requested assistance is not provided
(This block MUST be completed by the initiating employee)
10. How did the taxpayer learn about the Taxpayer Advocate Service
IRS Forms or Publications
IRS Employee
Other (please specify)
Catalog Number 16965S
Page 2
(Rev. 5-2011)


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