OMB No. 1545-1504
Department of the Treasury - Internal Revenue Service
If sending Form 911
Application for Taxpayer Assistance Order (ATAO)
911
with another form or
Form
letter, put Form 911
(Taxpayer’s Application for Relief from Hardship)
on top.
(Rev. January 1997)
Note: If you have not tried to obtain relief from the IRS office that contacted you, use of this form may not be necessary. Use this form only after read-
ing the instructions for When To Use This Form. Filing this application may affect the statutory period of limitations. (See instructions for line 14.)
Section I.
Taxpayer Information
2. Your Social Security Number
4. Tax form
1. Name(s) as shown on tax return
3. Social Security of Spouse Shown in 1.
5. Tax period ended
6.Current mailing address (number & street). For P.O. Box,
Apt. No.
see instuctions
8. Employer identification number, if applicable.
9. Person to contact
7. City, town or post office, state and ZIP Code
10. Daytime telephone number
11. Best time to call
If the above address is different from that shown on lastest filed tax return and you
(
)
want us to update our records with this new address, check here.......
12. Description of significant hardship (If more space is needed, attach additional sheets.)
A
T
A
13. Description of relief requested (If more space is needed, attach additional sheets.)
O
14. Signature of taxpayer or Corporate Officer.
15. Date
16. Signature of spouse shown in block 1
17. Date
(See instructions.)
Section II.
Representative Information (If applicable)
18. Name of authorized representative (Must be same as on Form 2848 or 8821)
22. Firm name
19. Centralized Authorization File (CAF) number
23. Mailing address
20. Daytime telephone number
21. Best time to call
24. Representative Signature
25. Date
Section III.
(For Internal Revenue Service only)
26. Name of initiating employee
27.
28. Telephone
29. Function 30. Office
31. Date
IRS Identified
(
)
Taxpayer request
ATAO Code
How received
Date of Detemination
PRO signature
911
Cat. No. 16965S
Form
(Rev. 1-97)
1
2
