Free Form 14017 (Rev. 7-2008) - Federal

Application for Fast Track Settlement
Submitted to Appeals: Date Location Taxpayer Name Taxpayer TIN/EIN Address City Telephone State Fax Zip Tax Years From: LM/SB Type of Tax SB/SE TE/GE Other Representative Name (If Applicable) Name of Firm Address City Telephone State Fax Source (FE/OE/CO, etc) Zip Telephone Fax Zip

Examination Group / Team Manager City State

Other Participants (if Applicable) Name Position or Affiliation Phone

Signatures The undersigned request Appeals assistance in the Fast Track Settlement (FTS) process. The issues for which this assistance is requested are described in the Form(s) 5701, Summary of Issues or Examination Re-Engineering Lead Sheets or similar documents and the taxpayer's written response, and are attached to this application. By signing this application, taxpayer consents, pursuant to section 6103(c) of the Code, to the disclosure of the taxpayer's returns and return information pertaining to the issues being considered in the FTS process to those persons named on the application as participants in the process. The prohibition against ex parte communications between Appeals personnel and other Service employees provided by section 1001(a) of the Internal Revenue Service Restructuring and Reform Act of 1998 does not apply to the communications arising in FTS because Appeals personnel, in facilitating an agreement between the taxpayer and the other Service Operating Division, are not acting in their traditional Appeals settlement role. IRS employees, taxpayer and persons invited to participate by the IRS or taxpayer will not voluntarily disclose information regarding any communication made during the FTS session, except as provided by statute.

Taxpayer Signature Taxpayer Spouse's Signature (If related to a joint return) Taxpayer(s) Representative Signature IRS Group / Team Manager Signature Approving Operating Division Official (Signature and Title) Accepted By Appeals Official (Appeals Team Manager Signature) Accepted By Appeals Official (Appeals Program Manager Signature) Internal Use Only
Industry (IC) Industry: NR; Coordinated Industry Case (CIC) HMT; RFPH; CTM; Other FS MFT: PBC:

Date signed Date signed Date signed Date signed Date signed Date signed Date signed

Potential Joint Committee Listed Transaction Fast Track End Date

Yes Yes

No No

Preferred Conference Site Form 14017 (Rev. 7-2008) Catalog Number 51767Y www.irs.gov

Department of the Treasury - Internal Revenue Service