Claim for Refund and Request for Abatement 
Form   843                                                                                                                                  OMB No. 1545-0024 
(Rev. August 2011) 
Department of the Treasury                               ▶ See separate instructions.
Internal Revenue Service 
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(s)                                                                                                Your social security number 

Address (number, street, and room or suite no.)                                                        Spouse’s social security number 

City or town, state, and ZIP code                                                                      Employer identification number (EIN) 

Name and address shown on return if different from above                                               Daytime telephone number 

1      Period. Prepare a separate Form 843 for each tax period or fee year.                            2     Amount to be refunded or abated:
       From                                              to                                                  $ 
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. 
        Employment                        Estate            Gift                            Excise           Income                                 Fee
4      Type of penalty. If the claim or request involves a penalty, enter the Internal Revenue Code section on which the penalty is 
       based (see instructions). IRC section: 
5 a    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.) 
        Interest was assessed as a result of IRS errors or delays. 
        A penalty or addition to tax was the result of erroneous written advice from the IRS. 
        Reasonable  cause  or  other  reason  allowed  under  the  law  (other  than  erroneous  written  advice)  can  be  shown  for  not 
        assessing a penalty or addition to tax. 
b      Date(s) of payment(s) ▶

6      Original return. Indicate the type of fee or return, if  any, filed to which the tax, interest, penalty, or addition to tax relates. 
        706                           709         940                                  941         943                                      945 
        990-PF                        1040        1120                                 4720        Other (specify) ▶
7      Explanation. Explain why you believe this claim or request should be allowed and show the computation of the amount shown 
       on line 2. If you need more space, attach additional sheets. 

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 (Title, if applicable. Claims by corporations must be signed by an officer.)                              Date

Signature (spouse, if joint return)                                                                                 Date
            Print/Type preparer’s name            Preparer's signature                             Date
Paid                                                                                                               Check         if         PTIN
                                                                                                                   self-employed
Preparer                            ▶                                                                  Firm's EIN  ▶
            Firm’s name     
Use Only                            ▶                                                                  Phone no.
            Firm's address  
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                     Cat. No. 10180R                          Form 843 (Rev. 8-2011)