Tax Collection Due Process Hearing Request Form

Taxpayer Full Name

First NameMiddle NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number

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

Email Address

example@example.com

Taxpayer Type

Are you represented?

Representative name

First NameLast Name

Firm or organization

Representative phone number

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

Representative email address

example@example.com

Representative mailing address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Type of Collection Action Challenged

Date of Notice or Action

Date

Case or Notice Reference Number

Tax Year or Tax Periods Involved

Hearing Request Format

Reason for Hearing and Description of Collection Issue

Preferred hearing format

Other

Preferred hearing location

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Available dates and times

Accessibility needs

Language assistance needed

Supporting Documents

Declaration

Signature