Form 13369 - Agreement to Mediate (2003)

Agreement to Mediate
Date
To: Appeals Team Manager
Compliance Officer Information (The person to contact in Compliance about this case)
Date signed
Other Participants (if applicable)
Form 13369 (4-2003) Catalog Number 35327G
Department of the Treasury - Internal Revenue Service
www.irs.gov
IRS and Treasury employees who participate in any way in the mediation process and any person under contract to the IRS invited to participate, will be subject to the
confidentiality and disclosure provisions of the Internal Revenue Code, including I.R.C. sections 6103, 7213, 7213A, and 7431. See also 5 U.S.C. section 574. The parties
also acknowledge that IRS and all other Treasury employees involved in the mediation are bound by I.R.C. section 7214(a)(8) and must report information concerning
violations of any revenue law to the Secretary. The Mediator will have the right to ask either party for additional information if deemed necessary for a full understanding of
the issues being mediated. A copy of any submission a party gives to the mediator will be provided simultaneously to the other party.
The Taxpayer consents to the disclosure by the IRS of the Taxpayer's returns and return information incident to the mediation to any participant or observer for the Taxpayer,
including persons providing expert assistance for the IRS. If the mediation agreement is executed by a person pursuant to a power of attorney executed by the Taxpayer, that
power of attorney must clearly express the Taxpayer's grant of authority to consent to disclose the Taxpayer's returns and return information by the IRS to third parties, and a
copy of that power of attorney must be attached to this agreement.
Taxpayer's signature
Taxpayer's signature
Taxpayer's Representative signature
Compliance Officer's signature
Date signed
Date signed
Date signed
Name Position or Affiliation Phone (Include Area Code)
Name Position or Affiliation Phone (Include Area Code)
Name Position or Affiliation Phone (Include Area Code)
Name
Taxpayer's Identification Number (TIN)
Title
ID/Badge numberOffice telephone number
Year(s)
Source (FE/OE/CO, etc.) MFT
Type of Tax (1040, 1120 Emp., etc) or Collection Issue (CDP, OIC etc)
Taxpayer's name Phone (Include Area Code)
Home street address (P.O. Boxes are not allowed)
City State ZIP code
Representative's name Firm name
Office street address (P.O. Boxes are not allowed)
City State ZIP code
Office phone number (Include Area Code) FAX number (Include Area Code)
OMB No. 1545-1844
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Form 13369 - Agreement to Mediate (2003) PDF

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