Department of the Treasury — Internal Revenue Service 
Form 12277                                 Application for Withdrawal of Filed 
(October 2011)                        Form 668(Y), Notice of Federal Tax Lien
                                                 (Internal Revenue Code Section 6323(j)) 
1. Taxpayer Name (as shown on the Notice of Federal Tax Lien)          2.  Social Security/Employer Identification No. 

3. Taxpayer's Representative, if applicable, or Name and Title of contact person, if taxpayer is a business 

4. Address (Number, Street, P.O. Box) 

5. City                                          6. State              7. ZIP code       8. Phone Number 

9. Attach copy of the Form 668(Y), Notice of Federal Tax Lien, if available, OR, if you don't have a copy, provide the 
following information, if available: 
Serial number of Form 668(Y) (found near the top of the document)      Date Form 668(Y) filed 

Recording office where Form 668(Y) was filed 

10. Current status of the federal tax lien ("x" appropriate box) 
     Open                Released                Unknown 

11. Reason for requesting withdrawal of the filed Notice of Federal Tax Lien ("x" appropriate box(es)) 

     The Notice of Federal Tax Lien was filed prematurely or not in accordance with IRS procedures. 
     The taxpayer entered into an installment agreement to satisfy the liability for which the lien was imposed
     and the agreement did not provide for a Notice of Federal Tax Lien to be filed. 
           The taxpayer is under a Direct Debit Installment Agreement. 
     Withdrawal will facilitate collection of the tax. 
     The taxpayer, or the Taxpayer Advocate acting on behalf of the taxpayer, believes withdrawal is in the
     best interest of the taxpayer and the government. 

12. Explain the basis for the withdrawal request (attach additional sheets and other documentation that substantiates your 
request, as needed) 

               Under penalties of perjury, I declare that I have examined this application (including any accompanying 
               schedules, exhibits, affidavits, and statements) and, to the best of my knowledge and belief, it is true, 
               correct, and complete 
Affirmation 
               Signature (Taxpayer or Representative)            Title (if business)                   Date 

Catalog Number 27939C                                  www.irs.gov                               Form 12277 (Rev. 10-2011) 

                                                                                                                               Page 2 of 2 

                                                   General Instructions 

1.	  	 Complete the application. If the information you supply is                a. If a determination is made to withdraw the NFTL, we
       not complete, it may be necessary for the IRS to obtain                    will file a Form 10916(c), Withdrawal of Filed Notice of
       additional information before making a determination on the                Federal Tax Lien, in the recording office where the
       application.                                                               original NFTL was filed and provide you a copy of the
                                                                                  document for your records.
       Sections 1 and 2: Enter the taxpayer's name and                            b. If the determination is made to not withdraw the
       Social Security Number (SSN) or Employer                                   NFTL, we will notify you and provide  information
       Identification Number (EIN) as shown on the Notice of                      regarding your rights to appeal the decision. 
       Federal Tax Lien (NFTL).
                                                                     4.	  	 At your request, we will notify other interested parties 
       Section 3: Enter the name of the person completing                   of the withdrawal notice.  Your request must be in 
       the application if it differs from the taxpayer's name in            writing and provide the names and addresses of the 
       section 1 (for example, taxpayer representative).  For               credit reporting agencies, financial institutions, and/or 
       business taxpayers, enter the name and title of person               creditors that you want notified. 
       making the application.  Otherwise, leave blank.
                                                                            NOTE:  Your request serves as our authority to release the 
       Sections 4 through 8: Enter current contact information              notice of withdrawal information to the agencies, financial 
       of taxpayer or representative.                                       institutions, or creditors you have identified. 

       Section 9: Attach a copy of the NFTL to be withdrawn,         5.	  	 If, at a later date, additional copies of the withdrawal notice 
       if available.  If you don't have a copy of the NFTL but              are needed, you must provide a written request to the 
       have other information about the NFTL, enter that                    Advisory Group Manager. The request must provide:
       information to assist the IRS in processing your
       request.                                                                   a. The taxpayer's name, current address, and taxpayer
                                                                                  identification number with a brief statement
       Section 10: Check the box that indicates the current                       authorizing the additional notifications;.
       status of the lien.                                                        b. A copy of the notice of withdrawal, if available; and
       "Open" means there is still a balance owed with                            c. A supplemental list of the names and addresses of
       respect to the tax liabilities listed on the NFTL.                         any credit reporting agencies, financial institutions, or
       "Released" means the lien has been satisfied or is no                      creditors to notify of the withdrawal of the filed Form
       longer enforceable.                                                        668(Y). 
       "Unknown" means you do not know the current status
       of the lien.
                                                                            .	 	              Privacy Act Notice 
       Section 11: Check the box(es) that best describe the
       reason(s) for the withdrawal request. NOTE: If you are                    We ask for the information on this form to carry out the 
       requesting a withdrawal of a released NFTL, you                      Internal Revenue laws of the United States.  The primary 
       generally should check the last box regarding the best               purpose of this form is to apply for withdrawal of a notice of 
       interest provision.                                                  federal tax lien. The information requested on this form is 
                                                                            needed to process your application and to determine 
       Section 12: Provide a detailed explanation of the                    whether the notice of federal tax lien can be withdrawn. 
       events or the situation to support your reason(s) for the            You are not required to apply for a withdrawal; however, if 
       withdrawal request.  Attach additional sheets and                    you want the notice of federal tax lien to be withdrawn, you 
       supporting documentation, as needed.                                 are required to provide the information requested on this 
                                                                            form. Sections 6001, 6011, and 6323 of the Internal 
       Affirmation:  Sign and date the application. If you are              Revenue Code authorize us to collect this information. 
       completing the application for a business taxpayer,                  Section 6109 requires you to provide the requested 
       enter your title in the business.                                    identification numbers. Failure to provide this information 
                                                                            may delay or prevent processing your application; providing 
2.	  	 Mail your application to the IRS office assigned your                false or fraudulent information may subject you to penalties.
       account.  If the account is not assigned or you are 
       uncertain where it is assigned, mail your application to IRS,              Routine uses of this information include giving it to the 
       ATTN: Advisory Group Manager, in the area where you live             Department of Justice for civil and criminal litigation, and to 
       or is the taxpayer's principal place of business. Use                cities, states, the District of Columbia, and U.S. 
       Publication 4235, Advisory Group Addresses, to determine             commonwealths and possessions for use in administering 
       the appropriate office.                                              their tax laws. We may also disclose this information to 
                                                                            other countries under a tax treaty, to federal and state 
3.	    Your application will be reviewed and, if needed, you may            agencies to enforce federal nontax criminal laws, or to 
       be asked to provide additional information.  You will be             federal law enforcement and intelligence agencies to 
       contacted regarding a determination on your application.             combat terrorism. 

Catalog Number 27939C	  	                                       www.irs.gov                                  Form 12277 (Rev. 10-2011)