Free Form 13711 (10-2005) - Federal

Request for Appeal of Offer in Compromise
Please complete the information in the spaces below, including your signature and the date.
Taxpayer name(s) Taxpayer Identification Number(s)

Mailing address

Tax form number

City

Tax period(s) ended

State

ZIP Code

Identify the specific item(s) you don't agree with as shown on the Income and Expense Table (IET) and Asset and Equity Table (AET) you received with your rejection letter. In the space next to the item, provide a brief statement why you don't agree with our determination (for example: incorrect valuation of real estate, omitted mileage from vehicle deduction, etc.). Attach supporting documents and indicate on them which issue they apply. Additional pages may be attached. If you do not agree with the Service's analysis of economic hardship or ETA, please provide an explanation with documentation. Disagreed item Reason for disagreement Supporting Documentation Attached Yes No

Disagreed item

Reason for disagreement

Supporting Documentation Attached

Yes

No

Disagreed item

Reason for disagreement

Supporting Documentation Attached

Yes

No

Signature of Taxpayer(s)

Date

Signature of Taxpayer(s)

Date

If this application was prepared by someone other than the taxpayer, please fill in that person's name and address
Name Address

Name and signature of authorized representative (If a representative is signing this form, please attach a copy of your completed Form 2848, Power of Attorney and Declaration of Representative.) Name

Signature

Date

Your telephone number

Best time to call

Form 13711 (10-2005)

Cat. No. 40992F

www.irs.gov

Department of the Treasury - Internal Revenue Service