Director's Stamp

Form 843 (Date received)

(Rev. July 1974) Claim
Department of the Treasury
Internal Revenue Service

For Internal Revenue Service Use Only
7] Refund of taxes illegally, erroneously, or excessively collected.
Refund of amount paid for stamps unused, or used in error or excess.
{[] Abatement of tax assessed (not applicable to income, estate or gift taxes).

fe

&{ Name of taxpayer or purchaser of stamps
5
3
=| Number and street
a
\"City or town, State, and ZIP code
§
=
Fill in applicable items—Use attachments if necessary
a. Your social security number Spouse's number, if joint return | b. Employer identification number (if any)

|

¢. Internal Revenue Service office where return (if any) was filed

d. Name and address shown on return, if different from above

e. Period—if for tax reported on annual basis, prepare separate form for each taxable year | f. Kind of tax

From 19. tO 19...
g. Amount of assessment Dates of payment
$
h. Date stamps were purchased i. Amount to be refunded (If income tax, | j. Amount to be abated (not applicable to income,
| complete computation below) estate, or gift taxes)
$ $
k. Explain why you believe this claim should be allowed.
Computation of Income Tax Refund Income Tax
1 Tax withheld
2 Estimated tax paid
3 Tax paid with original return .
4 Any additional income tax paid
5 Total tax paid (add lines 14)
6 Your computation of correct tax . on rs
7 Amount of overpayment (line 5 less line 8)
8 Amount previously refunded... So
9 Net overpayment (line 7 less line 8). Enter here and in item i above

Under penalties of perjury, | declare that | have examined this claim, including a accompanying g schedules and statements, and to
the best of my knowledge and belief it is true, correct, and complete.

Signed _

Dated _

See instructions on reverse. Form 843 (Rev. 7-74)


Instructions

1, You may use Form 1040X or
Form 1120X to amend an individual
or corporation income tax return
Since these forms aré’designed for
quick processing. the Internal Rev-
enue Service prefers that they be
used rather than Form 843.

2. You must set forth in detail
under item k the reasons for filing
this claim.

3. If you filed a joint income tax
return for the year for which you are
filing this claim, both you and your
spouse should enter your social se-
curity numbers and sign this claim
even if only one had income. If you
have an employer identification
number. you should enter it also.

4. The claim may be made by
your agent. but the original or a true
copy of his power of attorney must
accompany the claim.

5. If you are filing the ciaim as
legal representative for a decedent
whose return you filed. you should
attach to the claim a statement that
you filed his return and are still act-
ing as his representative. If you did
not file the decedent's return, you
must attach to the claim certified
copies of the letters testamentary,
letters of administration. or similar
evidence to show your authority.

6. If a corporation is making the
claim, the officer authorized to sign
for the corporation shouid sign this
claim and show his title.

7. |f you are filing a claim for
excess social security (FICA) tax

withheld as a result of having more
tnan one employer during a calendar
year, include the names and ad-
dresses of your employers, and the
amount of wages received and FICA
employee tax withheld by each, as
part of your explanation in item k.
Do not claim excess tax withheld if
you have already claimed it on your
individual income tax return.

Where to File

If your claim reiates to alcohol
and tobacco taxes, see the regula-
tions pertaining to the particular tax
to determine whether you shod file
with the Regional Director. Bureau
of Alcohol, Tobacco and Firearms.
Otherwise. file your claim with the
Internal Revenue Service Center
where you filed your return.

FOR INTERNAL REWENUE SERVICE USE

ONLY

Transcript of Claimant’s Account

(Complete only as to miscellaneous excise taxes and alcohol, tobacco, and certain
other excise taxes imposed-tinder subtitles D and E, Internal Revenue Code.)

The following is a transcript of the record of this office covering the liability that is the subject of this claim

A—Assessed Taxes

Taxable Period { Faid, Abated, or Credited

Document Reference Amount

| |
and Class | mark
Of Tax | Locator No. | and Date | Assessed sont Fe, Amount ase cr, | Remarks
(@) &) | © | @  * 3) @ | (h)
| | i
| | | |
{
| | | | |
i | :
| —|
| | | I |
B—Purchase of Stamps
j ] . If Special Tax Stamp, State
To Whom Sold or Issued | Kind | Number eaten Pats ef | amount | Dozument | Period
! | Locator No. | Commencing
@ : 0) | wo o | (m) | (a) | ® |
| | | r |
| |
i
| | | | | |
i i i I i
Prepared by (initials) Date | Office

‘Ye US. GOVERNMENT PRINTING OFFICE :1974—O-S48-198

36-2717749