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Form 843 Tax Refund or Abatement Request

Lets taxpayers or their representatives ask the IRS to return money or remove interest and penalties, capturing the tax period, amount, tax type and the reasoning behind the request. Signature blocks cover the filer, spouse and paid preparer.

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Request for refund or abatement

Name

First Name

Last Name

Employer identification number (EIN)

Daytime telephone number

Address

Street Address

City

State / Province

ZIP / Postal Code

Name and address shown on the return, if different from above

Tax period

From

2. Amount to be refunded or abated ($)

3. Type of tax or fee: indicate the tax or fee to be refunded or abated, or to which the interest, penalty or addition relates

Income tax Employment tax Estate tax Gift tax Excise tax Fee

4. Type of penalty: if the claim involves a penalty, enter the Internal Revenue Code section on which it is based

5a. Interest, penalties and additions to tax: check the box that indicates the reason for your refund or abatement request (if none apply, go to line 6)

IRS error or delay Erroneous written advice from the IRS Reasonable cause Other reason

5b. Date(s) of payment(s)

6. Original return: indicate the type of return or fee filed to which the tax, interest, penalty or addition relates

Form 1040 Form 941 Form 940 Form 720 Form 706 Other

7. Explanation: explain why this claim should be allowed and show the computation of the amount on line 2

Declaration under penalty of perjury

Sign here

Signature

Sign here

Date

Spouse's signature (if joint return)

Sign here

Date

Preparer's printed name

First Name

Last Name

Preparer's signature

Sign here

Date

Check if self-employed

Yes No Not applicable

PTIN

Firm's name

Firm's EIN

Firm's address

Phone no.

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