PDF document

- 1 -

Department of the Treasury – Internal Revenue Service
Form 8546
(Rev. February 2013) Claim for Reimbursement of Bank Charges
Instructions
Please carefully read the instructions on the back of this form and provide the information requested. Use additional
sheet(s) if necessary. Submit this form to the address of the IRS office which served the levy, the address of the office
that misplaced the payment or the address that you used to file your tax return for Direct Debit Installment Agreement
Request.
1. Name and address of claimants (Number, street, city, state, and ZIP code) 2. Telephone number (including area code)

3. Best time to call 4. Amount of claim
$
5. Social security or employer identification number
(Disclosure is voluntary. Omission may delay your claim
or prevent locating your records.)

Electronic Funds Transfer (EFT) Information
(See instructions on the back of this form.)
6. Name(s) on bank account 7. American Bankers Association (ABA) number

8. Bank name and address (Number, street, city, state, ZIP code) 9. Bank account number

10. Type of account

Checking Savings

11. Description of claim (State the circumstances which resulted in the loss for which you are claiming reimbursement.)

I certify that the amount of my claim covers only bank charges which resulted from either an
erroneous IRS levy, processing error by the Service for a Direct Debit Installment
Certification
Agreement or having to stop payment on a check which was lost or misplaced by the IRS. I
agree to accept this amount in full satisfaction and final settlement of this incident.
12. Signature of claimants (This signature should be used in all future correspondence.) 13. Date of claim

Civil Penalty for Presenting Civil Penalty for Presenting
Fraudulent Claim Fraudulent Claim or Making False Statements
The claimant shall be liable to the United States for the sum of Fine of not more than $10,000 or imprisonment for not more
$2,000 plus double the amount of damages sustained by the than 5 years or both. (See 62 Stat. 698, 749; 18 USC 287, 1001.)
United States. (See R S § 3490, 5438, 31 USC 3729.)

Catalog Number 63488O www.irs.gov Form 8546 (Rev. 2-2013)

- 2 -

Instructions
Please complete all blocks. Write "NONE" if the block does not apply.
Use this form only for reimbursement of bank charges for: 2. records showing the bank charges caused by the erroneous
levy, the request for replacement of a lost or misplaced
1. an erroneous levy, or check, or DDIA processing error on the part of the Service,
2. stopping payment on a check that the IRS lost or misplaced. and
3. Direct Debit Installment Agreement (DDIA) processing error 3. records showing that the bank charges have been paid.
on the part of the Service.
Records to support your claim must include bank statements and
The claimants must sign this form. If the bank account involved correspondence.
is a joint account, each owner on the account must sign the
Form 8546 as a claimant for erroneous levy. DDIA processing If you have any questions about this claim, please contact the
error claims on joint returns also require signature of both IRS office that issued the levy or requested replacement of your
spouses. However, an authorized agent or legal representative check. The address is on your copy of the levy or the request for
can file and sign the claim if the claimant can't because of a new check. If your questions relate to a Direct Debit Installment
disability, death, or other acceptable reason. Include proof of Agreement, please contact the IRS at 1-800-829-1040 or mail
authorization if the claim is being filed on behalf of someone. your questions to the address that you used to file your tax
return.
Claims must be made within one year of the date the claim
accrues and are limited to $1,000. (See 31 USC 3723) If IRS approves your claim, the money can be sent to your bank
by electronic funds transfer (EFT), or we can send you a check.
Please attach verification of the amount you are claiming. Payment by EFT will be faster, safer, and more convenient for
Include any documentation you may have explaining or you. If you want us to pay your claim by EFT, we need the bank
acknowledging the IRS error. Also, include: information in items 6 through 10. The American Bankers
Association (ABA) number (item 7) is the first nine digits in the
1. a copy of the levy (if the charges were caused by an number at the bottom of your checks. If you have no checking
erroneous levy), account, ask your bank what its ABA number is. If you do not
complete items 6 through 10, a check will be sent to you.

Internal Revenue Policy P-5-39
Reimbursement of Bank Charges Due to Erroneous Levy and Service Loss or Misplacement of Taxpayer
Checks, or Direct Debit Installment Agreement Processing Errors.
The Service recognizes that there are circumstances when an (3) Prior to the levy, the taxpayer did not refuse (either orally or
erroneous use of its unique enforcement powers may cause tax- in writing) to timely respond to Service inquiries or provide infor-
payers to incur certain bank charges. Taxpayers who incur bank mation relevant to the liability for which the levy was made.
charges due to an erroneous levy or a Direct Debit Installment
Agreement (DDIA) processing error on the part of the Service The following criteria must be present in all lost check cases:
may file a claim for reimbursement of those expenses. Bank (1) The Service acknowledges it lost or misplaced the check
charges include a financial institution's customary charge for during processing;
complying with the levy instructions as well as charges for
overdrafts that are a direct consequence of an erroneous levy or (2) the Service asks the taxpayer for a replacement of the pay-
DDIA processing error on the part of the Service. In addition, ment; and
there are times when a taxpayer's check may be lost or (3) the Service is satisfied that the replacement payment has
misplaced in processing. When the Service asks for a been received.
replacement check, the taxpayer maybe reimbursed for bank
charges incurred in stopping payment on the original check. The The following criteria must be present in all DDIA processing
charges must have been paid by the taxpayer and must not have error cases.
been waived or reimbursed by the financial institution. Claims (1) The Service failed to act timely, took an incorrect or
must be filed with the District Director or Service Center Director improper action, or a systemic failure caused the bank fees;
within one year after accrual of the expense.
(2) The taxpayer must not have contributed to the continuation
The following criteria must be present in all erroneous levy or compounding of the error that caused the bank fees; and
cases: (3) Prior to the processing error, the taxpayer did not refuse
(1) The Service acknowledges the levy was erroneous; (either orally or in writing) to timely respond to the Service’s
inquiries or provide sufficient information for the DDIA processing
(2) The taxpayers must not have contributed to the change to be made.
continuation or compounding of the error; and

In compliance with the Privacy Act of 1974, the following is provided.

Solicitation of the information is authorized by Title 31 USC We may disclose the information on this form relevant to the
3723; 31 CFR 3.20 et seq. Disclosure of the information is processing of your claim or to any court proceedings resulting
voluntary. from your claim. We may give the information to the Department
of Justice for the purpose of seeking legal advice or recommend-
The principal purpose of this information will be for our internal ing prosecutions for fraudulent claims or the making of false
use in processing your claim under 31 USC 3723, or for any statements.
court proceedings which may ensue from the filing of this claim.

Catalog Number 63488O www.irs.gov Form 8546 (Rev. 2-2013)

PDF file checksum: 123350139

(Plugin #1/7.24/11.3)