rom 843

(Rev. December 1987)

Department of the Treasur .
internal Revenue Service > See Instructions on back.

Claim OMB No. 1545-0024
Expires 9/30/90

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)
sl ( )
g| Number and street
2
SI City, town, or post office, state, and ZIP code
$
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 19 $

7 Dates of payment

8 Type of tax or penalty

_] Employment Clestate [J] excise [] itt [] stamp [] Penalty IRC section >
9 Kind of return filed

[}70e [1709 [)7201RSNo.(s)> Clea C1941 () 990PF [] 2290 CL) 4720
LJ other (specify) >
10 If this claim involves refund of excise taxes on gasoline or special fuels, 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 of interest or penalty.

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
Oo Refund of taxes illegally, erroneously, or excessively collected
O 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. 12:87)



Form 843 (Rev. 12-87)

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.

New section 6404(e) gives IRS the authority to
abate interest in cases where the additional
interest was caused by IRS errors and delays.
Section 6404(e) applies only if there was an error
or delay in performing a ministerial act (defined
below) and only relates to a tax of the type for
which a notice of deficiency 1s required by section
6212(a), which includes the taxes relating to
income, generation-skipping, estate, gift, and
certain excise taxes imposed by chapter 41, 42,
43, 44, or 45. Section 6404(e) does not
authorize the abatement of interest for
employment taxes or other excise taxes.
Ministerial Act. The term “ministerial act”
means a procedural or mechanical act that does
not involve the exercise of judgment or discretion
and that occurs during the processing of your
case after all prerequisites of the act, such as
conferences and review by supervisors, have
taken place. Get Publication 556, Examination
of Returns, Appeal Rights, and Claims for
Refund, for more information.

Special Instructions for Requesting Abatement
of Interest Under Section 6404(e). Across the
top of Form 843, write “Request for Abatement
of Interest under Rev. Proc. 87-42,” fill in your
name and address, and complete lines 1 through
4, whichever are applicable

Line 5 should state the tax period involved.

Skip lines 6, 8, and 9.

Line 7 should show dates of any payment of
interest or tax liability with respect to the tax
period and type of tax to which the claim relates

Line 11 should state the type of tax involved,
when you were first contacted by the Service in
writing with respect to the deficiency or payment,
the specific period for which you are requesting
abatement of interest, the circumstances of your
case, and the reason or reasons why you believe
that failure to abate the interest would result in
grossly unfair treatment

A separate Form 843 should be filed for each
tax period for each type of tax. However, if the
interest assessment resulted from the Service's
error or delay in performing a single ministerial
act that affected a tax assessment for multiple
tax years or types of tax (for example, where 2 or
more tax years were under examination), only
one Form 843 1s required.

Special instructions for requesting refund,
credit, or abatement of interest treated as
erroneously paid or assessed as a result of the
amendment of section 6601(c). Taxpayers may
recover or have abated, interest imposed with
respect to the suspension period on interest that
accrued before January 1, 1988. A clam for
refund or credit must be filed within 3 years from
the time the return of tax to which the interest
relates was filed or within 2 years from the time
the interest was paid, whichever is later.

If you are filing for a refund of suspension
period interest, write across the top of Form 843
“Request filed under Rev. Proc. 87-43” and leave
lines 5, 6, 8, and 10 blank. Line 7 should show
the date the interest was paid if known and state
whether the claim is for a credit or refund. Leave
line 7 blank if the interest has been assessed but
not paid.

The following statement should be included on
line 11: "Interest on a deficiency of ....... (enter
the type of tax; e.g., income, estate, or gift tax) for
the tax period ending ______. was suspended
pursuant to section 660(¢) of the Internal
Revenue Code. This is a claim for credit, refund,
or abatement of the interest collected or assessed
for the period the suspension was in effect.”
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 clam as a legal
representative for a decedent whose return you
filed, attach to the clam 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 how 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
onan overpayment made on a joint return, such
as a refund for overpaid Windfall Profits Tax,
each spouse's social security number must be
entered.

Line 8. Check the appropriate box to show the
type of tax or penalty. If you are filing a clam 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, check
the penalty box and enter 6700 in the space
provided. 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 1s 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 1s 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 subyect of this claim.

A—Assessed Taxes

Tax Period Paid, Abated, or Credited
and Ciass Document Reference Amount Date or ‘Amount PD. Remark
‘of Tax Locator No. and Date Assessed cone moun aoc, fermarks
@ | © @ () 0) (e) O)
B—Purchase of Stamps
If Special Tax Stamp, State
Date of
To Whom Sold or Issued Kind Number Denomination Sale Amount Document Period
° " Locator No. | Commencing
@ 0) () 0) (mn) @ (0) )
Prepared by (initials) Date Office

BULS,

GOVERNMENT PRINTING OFFICE:

1988 203-909/89306