Form 13711 - Request For Appeal Of Offer In Compromise
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1
2Request for Appeal of Offer in Compromise
Provide the information required in the spaces below. You must sign and date this form.
Taxpayer name
Taxpayer Identification Number
Taxpayer name
Taxpayer Identification Number
Mailing address
Tax form number
City
State
ZIP Code
Tax period(s) ended
Taxpayer's current daytime phone number
Name of authorized representative
Mailing address
City
State
ZIP Code
Telephone number of authorized representative
Best time to call (during normal business hours)
If you disagree with a specific item shown on the Income and Expense Table and Assets and Equity table you received with your rejection
letter, identify the specific item(s). In the space next to the disagreed item, provide a brief statement indicating why you don't agree with our
determination (if the disagreed item is the value of future income, indicate that under "Disagreed Item," and provide an explanation under
"Reason for Disagreement"). There is room for more entries on the back of this form, and you may use additional pages, if necessary. Attach
supporting documents for each disagreed item you identify and indicate on them which issue they apply to. If you disagree with a reason for
the rejection stated in our letter but not discussed on the Table, identify what statement you disagree with, the reason you disagree and
attach any supporting documentation. Additional pages may be attached. If you do not agree with the Service's analysis of economic
hardship or Effective Tax Administration, please provide an explanation with documentation. If possible, attach a copy of the rejection letter
to this form.
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Certification of Taxpayer: Under penalties of perjury, I declare that to the best of my knowledge, the information contained herein is
true, correct, and complete.
Signature of Taxpayer
Date signed
Signature of Taxpayer
Date signed
Certification for authorized representative: Check the box that applies depending on whether you have personal knowledge.
Under penalties of perjury, I declare that I have submitted the protest and accompanying
documents and to the best of my knowledge, the information contained herein is true, correct,
Scan this QR Code with
and complete.
your smartphone or
s.gov/appeals
other device with a QR
Under penalties of perjury, I declare that I have submitted the protest and accompanying
documents, but I have no personal knowledge concerning the facts stated in the protest and
reader, or go to the
the accompanying documents.
website url shown, to
view more information
Signature of authorized representative (Attach a copy of your completed Form 2848,
about completing this
Power of Attorney and Declaration of Representative.)
form and other Appeals
Signature of authorized representative
Date signed
processes online.
13711
Catalog Number 40992F
Department of the Treasury - Internal Revenue Service
Form
(Rev. 3-2013)
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