Form 843 ‘OMB No. 1545-0024

(Rev. October 1981) Claim Expires 12-31-83

Department of the Treasury} Jn:
Internal Revenue Service } See Instructions on back

If your claim is for an overpayment of income taxes, do NOT use this form (see Instructions)

& Name of taxpayer or purchaser of stamps
8 ee ee
2] Number and street
& nnn
i City or town, State, and ZIP code
=
Fill in applicable items—Use attachments if necessary
1 Your social security number 2 Employer identification number

3 Internal Revenue Service Center where return (if any) was filed

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

5 Period—prepare separate form for each tax period : 6 Amount to be refunded or abated
From. 119 to 119 $
7 Dates of payment

8 Type of tax
[] Employment [J Estate —[] Excise [Gift [J Stamp

9 Kind of return filed
706 4709 [720 J 940 O94 (J 990-PF [ 4720 (1 Other (specify) >

10 If this claim involves refund of excise taxes on gasoline, special fuels or lubricating oil, please indicate your tax year for income
tax purposes

11 Explain why you believe this claim should be allowed and show computation of tax refund or abatement

Under penalties of perjury, | declare that | have exarnined this claim, including accompanying schedules and state- Director's Stamp
ments, and to the best of my knowledge and belief it is true, correct, and complete. (Date received)
Signed ... Dated 19.

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

For Paperwork Reduction Act Notice, see instructions on back. Form 843 (Rev. 10-81)


Paperwork Reduction Act No-
tice.—The Paperwork Reduction Act
of 1980 says we must tell you why
we are collecting this information,
how we will use it, and whether you
have to give it to us. We ask for the
information to carry out the Internal
Revenue laws of the United States.
We need it to ensure that you are
complying with these laws and to al-
low us to figure and collect the right
amount of tax. You are required to
give us this information.

Instructions

You can use this form to claim a
refund of certain taxes you overpaid
or an abatement of those you have
been overassessed. For example,
you can use it for overpayments of
employment taxes or excise taxes.

Do NOT use this form to make a
claim for overpayment of income
tax. Individuals who filed Form
1040 or 1040A must -use Form

1040X, Amended U.S. Individual In-
come Tax Return, to claim an over-
payment. Corporations who filed
Form 1120 must use Form 1120X,
Amended U.S. Corporation Income
Tax Return, to claim an overpay-
ment. Other income tax filers should
file a claim on the appropriate
amended tax return. (Follow the in-
structions on the appropriate form
for filing an amended return.)

Your agent may make a claim for
you. In this case, the original or a
copy of the power of attorney must
be attached to the claim.

If you are filing the claim as a
legal representative for a decedent
whose return you filed, attach to the
claim a statement that you filed the
return and are still acting as the rep-
resentative. If you did not file the
decedent’s return, attach to the
claim certified copies of letters
testamentary, letters of administra-
tion, or similar evidence to show
your authority.

If a corporation is making the
claim, the person authorized to act
in its behalf must sign the claim and
show title.

Completing the Return.—Fill in
all applicable items on the front of
this form. Be sure to check the ap-
propriate box in item 8 to show the
type of tax. Also check the appro-
priate box in item 9 to show the kind
of return that was filed.

In item 11 specify in detail the
reasons for filing the claim. You
must also show your computation of
the tax refund or abatement.

Where to File.—File your claim
with the Internal Revenue Service
Center where you filed your return.

If your claim is for alcohol and
tobacco taxes, see the regulations
on the particular tax to determine
whether you should file with the Re-
gional Director, Bureau of Alcohol,
Tobacco and Firearms.

FOR

INTERNAL REVENUE SERVICE USE ONLY

Transcript of Claimant's Account

(Complete only for miscellaneous excise taxes and alcohol, tobacco, and certain
other excise taxes imposed under 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

Tax Period id, Abated, or Credited

nd’ Glase | Document | Reference Amount oe oT] Remarks

nd Clas Locator No. | and Date Assessed bate Amount ase cr.
O) ) 3) @ © ) ® 0)
B——Purchase of Stamps

. if Special Tax Stamp, State:

To Whom Sold or Issued Kind Number Denomi- Data of Amount Document Perlod
Locator No. | Commencing

) @ | we © ) (n) Cy ©)
Prepared by (initials) Date Office

SrU.S. Government Printing Office: 1983~381-108/129