Form 12009                                  Department of the Treasury — Internal Revenue Service
(December 2006)          Request for an Informal Conference and Appeals Review 

Use this form to request an informal conference with an IRS Supervisor.  After your request is received and 
reviewed, the supervisor will contact you.  If this matter is not resolved at the supervisor level, at your request, 
we will send your case to the appropriate Appeals Office for an administrative appeal. 
Taxpayer Name(s):                                     Taxpayer Identification Number: 

Address: 

In the space below, please explain why you do not agree with the proposed IRS penalty.  Additional sheets 
may be used if needed.  Attach any supporting documentation. 

IRS Penalty:                                                                                                Penalty Date: 

                         (If more space is needed, attach an additional sheet) 

Signature:                                            Print Name: 

Date:                    Title:                                          Your Telephone Number(s): 

                         Send this completed form and any additional information to: 
                                    Internal Revenue Service 
Manager Name and I.D. #:                              Address: 

. . . . . . . . . . . . . . . . . . . . .Official. . .Use.  .Only. . . . . . . . . . . . . . . . . . . . . . .                                      .
Date of Taxpayer Request for Appeals Review                                Supervisor Date and Initial 

Catalog No. 25631V                          www.irs.gov                                                                   Form 12009 (Rev. 12-2006) 

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