Form 12153 - Request for a Collection Due Process or Equivalent Hearing (2013)

Form
12153
(Rev. 12-2013)
Request for a Collection Due Process or Equivalent Hearing
Form
12153
(Rev. 12-2013)
Catalog Number 26685D www.irs.gov
Department of the Treasury - Internal Revenue Service
Use this form to request a Collection Due Process (CDP) or equivalent hearing with the IRS Office of
Appeals if you have been issued one of the following lien or levy notices:
• Notice of Federal Tax Lien Filing and Your Right to a Hearing under IRC 6320,
• Notice of Intent to Levy and Notice of Your Right to a Hearing,
• Notice of Jeopardy Levy and Right of Appeal,
• Notice of Levy on Your State Tax Refund,
• Notice of Levy and Notice of Your Right to a Hearing.
Complete this form and send it to the address shown on your lien or levy notice. Include a copy
of your lien or levy notice to ensure proper handling of your request.
Call the phone number on the notice or 1-800-829-1040 if you are not sure about the correct address
or if you want to fax your request.
You can find a section explaining the deadline for requesting a Collection Due Process
hearing in this form's instructions. If you've missed the deadline for requesting a CDP
hearing, you must check line 7 (Equivalent Hearing) to request an equivalent hearing.
1. Taxpayer Name: (Taxpayer 1)
Taxpayer Identification Number
Current Address
City State Zip Code
2.
Telephone Number and Best Time
to Call During Normal Business
Hours
Home ( )
-
am. pm.
Work ( )
-
am. pm.
Cell
( )
-
am. pm.
3. Taxpayer Name: (Taxpayer 2)
Taxpayer Identification Number
Current Address
(If Different from
Address Above)
City State Zip Code
4.
Telephone Number and Best Time
to Call During Normal Business
Hours
Home
( )
-
am. pm.
Work ( )
-
am. pm.
Cell
( )
-
am. pm.
5. Tax Information as Shown on the Lien or Levy Notice (
If possible, attach a copy of the notice
)
Type of Tax (Income,
Employment, Excise,
etc. or Civil Penalty)
Tax Form Number
(1040, 941, 720, etc)
Tax Period or Periods
Page 1/4
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Form 12153 - Request for a Collection Due Process or Equivalent Hearing (2013) PDF

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