Application for Fast Track Settlement
Type of Tax
Submitted to Appeals
From
LB&I
SB/SE
TE/GE
Other
Date
Location
Taxpayer name
Representative name
(If applicable)
Taxpayer TIN/EIN
Tax years
Name of Firm
Address
Address
City
State
Zip
City
State
Zip
Telephone
Fax
Telephone
Fax
Examination Group / Team Manager
Source (
)
FE/OE/CO, etc
City
State
Zip
Telephone
Fax
Other Participants
(if applicable)
Name
Position or Affiliation
Phone
Signatures
The undersigned request Appeals assistance in the Fast Track Settlement (FTS) process. The issues for which this assistance is requested are
described in the Form(s) 5701, Summary of Issues or Examination Re-Engineering Lead Sheets or similar documents and the taxpayer’s written
response, and are attached to this application. By signing this application, taxpayer consents, pursuant to section 6103(c) of the Code, to the disclosure
of the taxpayer’s returns and return information pertaining to the issues being considered in the FTS process to those persons named on the application
as participants in the process. The prohibition against ex parte communications between Appeals personnel and other Service employees provided by
section 1001(a) of the Internal Revenue Service Restructuring and Reform Act of 1998 does not apply to the communications arising in FTS because
Appeals personnel, in facilitating an agreement between the taxpayer and the other Service Operating Division, are not acting in their traditional Appeals
settlement role. IRS employees, taxpayer and persons invited to participate by the IRS or taxpayer will not voluntarily disclose information regarding any
communication made during the FTS session, except as provided by statute.
Taxpayer Signature
Date signed
Taxpayer Spouse's Signature (
)
Date signed
If related to a joint return
Taxpayer(
) Representative Signature
Date signed
s
IRS Group / Team Manager Signature
Date signed
Approving Operating Division Official (
)
Date signed
Signature and Title
Accepted by Appeals Official (
)
Date signed
Appeals Team Manager Signature
Accepted by Appeals Official (
)
Date signed
Appeals Program Manager Signature
Industry (IC)
Coordinated Industry Case (CIC)
Other
Potential Joint Committee
Yes
No
MFT:
PBC:
Listed Transaction
Yes
No
Industry
NR
HMT
RFPH
CTM
FS
Preferred Conference Site
Fast Track End Date
14017
Catalog Number 51767Y
Department of the Treasury - Internal Revenue Service
Form
(Rev. 10-2010)