rom 843

(Rev. June 1976)

Department of the Treasury
Internal_Revenue Service

Claim

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

B] Name of taxpayer or purchaser of stamps
3
| Number and street
a
| City or town, State, and ZIP code
Hy
a

Fill in applicable items—Use attachments if necessary
1 Your social security number 2 Employer identification number
3 Internal Revenue Service office where return (if any) was filed

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

5 Period—prepare separate form for each taxable period 6 Amount to be refunded or abated
From 119 to ,19 $

7 Dates of payment

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

©

Kind of return filed

[706 [709 Fy 720 (J 940 o 941 [J 990-PF F) 4720 [1 Other (specify) >

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

Under penaities of perjury, | declare that | have examined this claim, including accompanying schedules and state-
ments, and to the best of my knowledge and belief it is true, correct, and complete.

SIgMEM oeeescscsesnseeneenrtneeentrnetnnetnttnenesttnennnetnetanenentecene secon Dated

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

Director's Stamp
(Date received)

16—82797-1 See instructions on back.

Form 843 (Rev. 6-76)


Instructions

If your claim is for an overpay-
ment of income taxes, do NOT use
Form 843. Individuals who filed
Form 1040 or 1040A file claim on
Form 1040X, Amended U.S. Individ-
ual Income Tax Return. Corporations
who filed Form 1120 file claim on
Form 1120X, Amended U.S. Corpo-
ration Income Tax Return. All other
income tax filers file claim on an
appropriate amended tax return.

You must set forth in detail under
item 10 the reasons for filing the
claim and show computation of tax
refund or abatement.

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

lf you are filing the claim as le-
gal representative for a decedent
whose return you filed, you should
attach to the claim a statement that
you filed the return and are still act-
ing as the 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.

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

Where to File

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

If your claim relates to alcohol
and tobacco taxes, see the regula-
tions pertaining to the particular tax
to determine whether you should file
with the Regional Director, Bureau
of Alcohol, Tobacco and Firearms.

FOR INTERNAL REVENUE SERVICE USE ONLY

Transcript of Claimant’s Account

(Complete only as to 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

i Paid, Abated, or Credited
Taxa ofes’’| Document | Reference Amount Remarks
‘of Tax Locator No. and Date Assessed Sorts, %o, Amount ase cr.
@ (by © @ ©) 0) @ ne)
B—Purchase of Stamps
; If Special Tax Stamp, State:
To Whom Sold or Issued Kind Number Denomi- Date of Amount Document Perio
Locator No. | Commencing
@ @ w 0} (my (n) © )
Prepared by (initials) Date Office

‘Ye US. GOVERNMENT PRINTING OFFICE :1996—-O-575-267