Form 843 - Tax Abatement Form

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

First NameLast Name

Employer identification number (EIN)

Daytime telephone number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name and address shown on return if different from above

1. Period: Prepare a separate Form 843 for each tax period or fee year.

From

Date

To

Date

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.

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

5a. 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)

5b. Date(s) of payment(s)

Date

6. Original return: Indicate the type of fee or return, if any, filed to which the tax, interest, penalty, or addition to tax relates.

7. Explanation: Explain why you believe this claim or request should be allowed and show the computation of the amount shown on line 2.

8. 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

Date

Spouse Signature (if joint return)

Date

Print/Type preparer's Name

First NameLast Name

Preparer's Signature

Date

Check if self-employed

PTIN

Firm’s Name

Firm's EIN

Firm's Address

Phone No.

Format: (000) 000-0000.

Claim for Refund and Request for Abatement

Paid Preparer Use Only