Form 843

OMB No. 1545-0024

Claim for Refund and Request for Abatement

(Rev. February 2009)

Department of the Treasury

Internal Revenue Service © See separate instructions.

Use Form 843 if your claim or request involves:

Daytime telephone number

Name(s)

( )

Address (number, street, and room or suite no.)

City or town, state, and ZIP code

Spouse’s social security number

Your social security number

Employer identification number (EIN)

Name and address shown on return if different from above

1 Period. Prepare a separate Form 843 for each tax period 2 Amount to be refunded or abated

From / / to / / $

7 Explanation. Explain why you believe this claim or request should be allowed and show the computation of the amount shown 

on line 2. If you need more space, attach additional sheets.

Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and, to the best of my knowledge and

belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Signature (Title, if applicable. Claims by corporations must be signed by an officer.) Date

Signature (spouse, if joint return) Date

Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must sign the claim.

Claims filed by corporations must be signed by a corporate officer authorized to sign, and the officer’s title must be shown.

Do not use Form 843 if your claim or request involves:

an overpayment of income taxes or an employer’s claim for FICA tax, RRTA tax, or income tax withholding (use the

appropriate amended tax return),

an overpayment of excise taxes reported on Form(s) 11-C, 720, 730, or 2290.

a refund of excise taxes based on the nontaxable use or sale of fuels, or

a refund of one of the taxes (other than income taxes and an employer’s claim for FICA tax, RRTA tax, or income

tax withholding), shown on line 3,

an abatement of FUTA tax or certain excise taxes, or

(a)

(b)

(c) a refund or abatement of interest, penalties, or additions to tax for one of the reasons shown on line 5a.

(a)

(b)

(c)

Date(s) of payment(s) ©

3 Type of tax. Indicate the type of tax to be refunded or abated or to which the interest, penalty, or addition to tax is related.

Employment

Type of penalty. If the claim or request involves a penalty, enter the Internal Revenue Code section on which the penalty

is based (see instructions). IRC section:

Estate Gift

4

Interest was assessed as a result of IRS errors or delays.

A penalty or addition to tax was the result of erroneous written advice from the IRS.

709

990-PF 1120

706 940 945

Excise

Other (specify) ©

943

Income

Interest, penalties, and additions to tax. Check the box that indicates your reason for the request for refund or

abatement. (If none apply, go to line 6.)

5a

Reasonable cause or other reason allowed under the law (other than erroneous written advice) can be shown for not

assessing a penalty or addition to tax.

b

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

Preparer’s Date Preparer’s SSN or PTIN

signature Check if

self-employed Paid

Preparer’s

Use Only Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN

©

© Phone no. ( )

941

1040 4720