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Use this form to request
a hearing with the IRS Office of Appeals only when you receive a Notice of
Federal Tax Lien Filing & Your Right To A Hearing Under IRC 6320, a Final
Notice - Notice Of Intent to Levy & Your Notice Of a Right To A Hearing, or
a Notice of Jeopardy Levy and Right of Appeal. Complete this form and
send it to the address shown on your lien or levy notice for expeditious
handling. Include a copy of your lien or levy notice(s) to ensure proper
handling of your request.
{Print} Taxpayer Name(s):
____________________________________________________________________
{Print}Address:
____________________________________________________________________________
Daytime Telephone Number:_______________________Type of Tax/Tax Form
Number(s): ________________
Taxable
period(s):__________________________________________________________________________
Social Security
Number/Employer Identification Number(s):_____________________________________________
___________________________________________________________
Check the IRS action(s) that you do not agree with.
Provide specific reasons why you don't agree. If you believe that your
spouse or former spouse should be responsible for all or a portion of the tax
liability from your tax return, check here [_] and attach Form 8857, Request
for Innocent Spouse Relief, to this request.
X Filed Notice of Federal Tax Lien
(Explain why you don't agree. Use extra sheets if necessary.)
I request collection alternatives including OIC and payment schedule. Collection actions are inappropriate. Procedural defects by Internal Revenue Service exist. I want to see copies of the 90-day letter, Notice and Demand letter (Form 17-A), also Summary Record of Assessment (Form 23-C) or replacement form, RACS Report and my form 4340 "Certificate of Assessment and Payments" and proof that they were sent. See Extra Sheet Attached.
X Notice of Levy/Seizure (Explain why you don't
agree. Use extra sheets if necessary.)
I request collection alternatives including OIC and payment schedule. Collection actions are inappropriate. Procedural defects by Internal Revenue Service exist. I want to see copies of the 90-day letter, Notice and Demand letter (Form 17-A), also Summary Record of Assessment (Form 23-C) or replacement form, RACS Report and my form 4340 "Certificate of Assessment and Payments" and proof that they were sent. See Extra Sheet Attached.
I/we understand that the
statutory period of limitations for collection is suspended during the
Collection Due Process Hearing and any subsequent judicial review.
Taxpayer's or Authorized
Representative's Signature and Date:______________________________________
Taxpayer's or Authorized Representative's
Signature and Date:______________________________________
IRS
Use Only:
IRS Employee {Print}________________________________ IRS Received
Date:___________________________
Employee Telephone Number:_____________________________
Form 12153 (01-1999) Catalog Number 26685D Department
of the Treasury - Internal Revenue Service
(Over)