Form 13711
Request for Appeal of Offer in Compromise
Form 13711 (Rev. 3-2013)
Catalog Number 40992F www.irs.gov Department of the Treasury - Internal Revenue Service
Service employee - Staple the taxpayer's envelope here
Provide the information required in the spaces below. You must sign and date this form.
Taxpayer name Taxpayer Identification Number
Taxpayer name Taxpayer Identification Number
Mailing address
City State ZIP Code
Taxpayer's current daytime phone number
Tax form number
Tax period(s) ended
Name of authorized representative
Mailing address City State ZIP Code
Telephone number of authorized representative
Best time to call (during normal business hours)
If you disagree with a specific item shown on the Income and Expense Table and Assets and Equity table you received with your rejection
letter, identify the specific item(s). In the space next to the disagreed item, provide a brief statement indicating why you don't agree with our
determination (if the disagreed item is the value of future income, indicate that under "Disagreed Item," and provide an explanation under
"Reason for Disagreement"). There is room for more entries on the back of this form, and you may use additional pages, if necessary. Attach
supporting documents for each disagreed item you identify and indicate on them which issue they apply to. If you disagree with a reason for
the rejection stated in our letter but not discussed on the Table, identify what statement you disagree with, the reason you disagree and
attach any supporting documentation. Additional pages may be attached. If you do not agree with the Service's analysis of economic
hardship or Effective Tax Administration, please provide an explanation with documentation. If possible, attach a copy of the rejection letter
to this form.
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Certification of Taxpayer: Under penalties of perjury, I declare that to the best of my knowledge, the information contained herein is
true, correct, and complete.
Signature of Taxpayer Date signed Signature of Taxpayer Date signed
Certification for authorized representative: Check the box that applies depending on whether you have personal knowledge.
Under penalties of perjury, I declare that I have submitted the protest and accompanying
documents and to the best of my knowledge, the information contained herein is true, correct,
and complete.
Under penalties of perjury, I declare that I have submitted the protest and accompanying
documents, but I have no personal knowledge concerning the facts stated in the protest and
the accompanying documents.
Signature of authorized representative (Attach a copy of your completed Form 2848,
Power of Attorney and Declaration of Representative.)
Signature of authorized representative Date signed
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Request for Appeal of Offer in Compromise
Form 13711 (Rev. 3-2013)
Catalog Number 40992F www.irs.gov Department of the Treasury - Internal Revenue Service
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Disagreed Item
Reason for Disagreement (attach supporting documentation)
Disagreed Item
Reason for Disagreement (attach supporting documentation)
