Form ***

(Rev. August ****)

Department of the Treasury

Internal Revenue Service

Claim for Refund and Request for Abatement

See separate instructions.

OMB No. 1545-0024

Use Form 843 if your claim or request involves:

(a) a refund of one of the taxes (other than income taxes or an employer’s claim for FICA tax, RRTA tax, or income tax withholding) or a fee, shown on line 3,

(b) an abatement of FUTA tax or certain excise taxes, or

(c) a refund or abatement of interest, penalties, or additions to tax for one of the reasons shown on line 5a. Do not use Form 843 if your claim or request involves:

(a) an overpayment of income taxes or an employer’s claim for FICA tax, RRTA tax, or income tax withholding (use the appropriate amended tax return),

(b) a refund of excise taxes based on the nontaxable use or sale of fuels, or

(c) an overpayment of excise taxes reported on Form(s) 11-C, 720, 730, or 2290. Name(s) Your social security number

Address (number, street, and room or suite no.) Spouse’s social security number City or town, state, and ZIP code Employer identification number (EIN) Name and address shown on return if different from above Daytime telephone number 1 Period. Prepare a separate Form 843 for each tax period or fee year. From to

2 Amount to be refunded or abated:

$

3 Type of tax or fee. Indicate the type of tax or fee to be refunded or abated or to which the interest, penalty, or addition to tax is related.

Employment Estate Gift Excise Income Fee

4 Type of penalty. If the claim or request involves a penalty, enter the Internal Revenue Code section on which the penalty is based (see instructions). IRC section:

5 a Interest, penalties, and additions to tax. Check the box that indicates your reason for the request for refund or abatement. (If none apply, go to line 6.)

Interest was assessed as a result of IRS errors or delays. A penalty or addition to tax was the result of erroneous written advice from the IRS. Reasonable cause or other reason allowed under the law (other than erroneous written advice) can be shown for not assessing a penalty or addition to tax.

b Date(s) of payment(s)

6 Original return. Indicate the type of fee or return, if any, filed to which the tax, interest, penalty, or addition to tax relates. 706-***-***-*** 943 945

990-PF 104*-****-**** Other (specify)

7 Explanation. Explain why you believe this claim or request should be allowed and show the computation of the amount shown on line 2. If you need more space, attach additional sheets. Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must sign the claim. Claims filed by corporations must be signed by a corporate officer authorized to sign, and the officer’s title must be shown. Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and, to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Signature (Title, if applicable. Claims by corporations must be signed by an officer.) Date Signature (spouse, if joint return) Date

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 10180R Form 843 (Rev. 8-2011) Paid

Preparer

Use Only

Print/Type preparer’s name Preparer's signature Date Check if

self-employed

PTIN

Firm’s name Firm's EIN

Firm's address Phone no.

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