Department of the Treasury - Internal Revenue Service
Form 12256 
(October 2012)       Withdrawal of Request for Collection Due Process or Equivalent Hearing

Taxpayer name(s)

Taxpayer address

City                                                         State                                       Zip code

Type of tax/tax form*

Tax period(s)*

Social Security/Employer Identification Number(s)* 

*Note:  You may attach a copy of your Collection Due Process noticeto this form instead of listing the tax type/form number/period 
        and identification number in the spaces above.  
I've reached a resolution with the Internal Revenue Service (IRS) regarding the tax and tax periods that my hearing request concerned 
or I am otherwise satisfied that I no longer need a hearing with the Office of Appeals (Appeals). Therefore, I withdraw my hearing 
request under (check all that apply):  
IRC Section 6320, notice and opportunity for a hearing upon the filing of a Notice of Federal Tax Lien 
IRC Section 6330, notice and opportunity for a hearing before a levy
Both IRC Section 6320 and 6330 notices
Equivalent Hearing 
I understand that by withdrawing my request for a Collection Due Process hearing under Section 6320 and/or 6330:
•  I give up my right to a hearing with Appeals. I understand that Appeals will not issue a Notice of Determination with 
     respect to the tax and tax periods subject to the hearing request. As part of a CDP determination, Appeals verifies 
     that all legal and administrative requirements were met. I understand that by withdrawing my hearing request, 
     Appeals will not conduct this verification. 
•  I give up my right to seek judicial review in the Tax Court of the Notice of Determination that Appeals would have  
     issued as a result of the CDP Hearing, as Appeals will not issue a Notice of Determination.  
•  I give up my right to have Appeals retain jurisdiction with respect to any determination that it would have made as a 
     result of the CDP Hearing.  
•  The suspension of levy action and the suspension of the statute of limitations on the period of collection, as required 
     under the provisions of IRC Sections 6320 and 6330, are no longer in effect upon the receipt by the IRS of this 
     withdrawal.  
•  I do not give up any other appeal rights that I am entitled to, such as an appeal under the Collection Appeals  
     Program (CAP).
I understand that by withdrawing my request for an equivalent Hearing:
•  I give up my right to a hearing with Appeals. I understand that Appeals will not issue a Decision Letter with respect to the tax and 
     tax periods subject to the hearing request.   
•  I do not give up any other appeal rights that I am entitled to, such as an appeal under the Collection Appeals Program (CAP).
Taxpayer's signature                                                                                       Date

Spouse's signature (if applicable)                                                                         Date

Authorized Representative signature (if applicable)                                                        Date

                                       For privacy Act information please refer to Notice 609  
Catalog Number 27779K                                   www.irs.gov                                      Form 12256 (Rev. 10-2012)