rom 843

(Rev. April 1985) Claim OMB No. 1545-0024
Department of the Treasury | Expires 3/31/88
Internal Revenue Service » See Instructions on back.
If your claim is for an overpayment of income taxes, do NOT use this form (See Instructions)
(Use this form ONLY if your claim involves one of the taxes shown on line 8 or a refund or abatement of interest or penalties.)
E]_ Name of taxpayer or purchaser of stamps Telephone number (optional)
a ¢ )
g| Number and street
2
SI City, town, or post office, state, and ZIP code
3]
a
Fill in applicable items—Use attachments if necessary

1 Your social security number 2 Spouse’s social security number| 3 Employer identification number

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 19 ,to 119 $
7 Dates of payment

8 Type of tax or penalty
im Employment im Estate imi Excise im Gift oO Stamp O Penalty IRC section >

9 Kind of return filed
[1706 [1709 []7201RSNo.(s)> Feo [1941 (1 o90pr [] 2290 [ 4720
[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 examined this claim, including accompanying schedules and statements, and to the best Director's Stamp.
of my knowledge and belief it is true, correct, and complete.

(Date received)

Signature Date
For Internal Revenue Service Use Only

Ol Refund of taxes illegally, erroneously, or excessively collected

oO Refund of amount paid for stamps unused, or used in error or excess

oO Abatement of tax assessed (not applicable to estate or gift taxes)
For Paperwork Reduction Act Notice, see instructions on back. Form 843 (Rev. 4-85)



Form 843 (Rev. 4-85)

Page 2

Instructions

(Section references are to the Internal
Revenue Code.)

Paperwork Reduction Act Notice. —We
ask for this information to carry out the
Internal Revenue laws of the United States.
We need it to ensure that taxpayers are
complying with these laws and to allow us to
figure and collect the right amount of tax.
You are required to give us this information.

Purpose of Form.—This form can be used
to claim certain refunds and abatements.
Use Form 843 to file a claim for refund of
overpaid taxes (except in the case of income
tax), interest, penalties, and additions to
tax. For example, if on your employment tax
return, you reported and paid more Federal
income tax than was actually withheld from
an employee, use this form to claim a
refund.

Form 843 is also used to file a claim for
abatement of an overassessment or the
unpaid portion of an overassessment, if
more than the correct amount of tax (except
in the case of income, estate, and gift
taxes), interest, additional amount, addition
to tax, or assessable penalty has been
assessed.

General Instructions. —Do not use this
form to make a claim for overpayment of
income tax. Individuals who filed Form
1040, 1040A, or 1040EZ must use Form
1040X, Amended U.S. Individual Income

Tax Return, to claim an overpayment.
Corporations who filed Form 1120 or Form
1120-A, must use Form 1120X, Amended
U.S. Corporation Income Tax Return, to
claim an overpayment. Other income tax
filers should file a claim on the appropriate
amended tax return. (Follow the
instructions 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 representative. If you did not file the
decedent's return, attach to the claim
certified copies of 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 his/her title.

Specific Instructions. —Lines that are not
explained below are self-explanatory.

Lines 1 and 2.—If you are claiming a
refund based on an overpayment made on
ajoint return, such as a refund for overpaid
Windfall Profits Tax, each spouse must
enter his or her social security number.

Line 8.—Check the appropriate box to
show the type of tax or penalty. If you are

filing a claim for refund or abatement of an
assessed penalty, check the box and enter
the applicable Internal Revenue Code (IRC)
section. For example, if the penalty was
assessed under section 6700, Promoting
Abusive Tax Shelters, check the penalty box
and enter 6700 in the space provided for
the IRC section. Generally, the IRC section
can be found on the Notice of Assessment
you receive from the Service Center.

Line 9.—Check the appropriate box to
show the kind of return, if any, that was
filed. If the box for Form 720 is checked,
enter the IRS No.(s) in the space provided.
The IRS No. can be found on Form 720 to
the right of the entry space for the tax.

Line 11.—Specify in detail your reasons for
filing this claim and show your computation
for the credit, refund or abatement. Also
attach appropriate supporting evidence.

Signature.—If you are claiming a refund
based on an overpayment made on a joint
return such as a refund for overpaid
Windfall Profits Tax, each spouse must sign
the refund claim.

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 for that 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 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 Paid, Abated, or Credited
and Class Document Reference Amount Dacor Amount ~ remark
of Tax Locator No. and Date Assessed CT jount anor, ’emarks
@ ) ©) @) @) @ e) (hy
B—Purchase of Stamps
ate of If Special Tax Stamp, State:
To Whom Sold or Issued Kind Number | Denomination Sale. Amount Document Period
Locator No, | Commencing
@ ) &) (0) (m) () (0) (e)
Prepared by (initials) Date Office