Department of the Treasury - Internal Revenue Service
Form 12661 
(October 2015)                                Disputed Issue Verification

Taxpayer name

Tax period                                    Social Security Number

Instructions for completing disputed issues
Please complete a separate block for each issue or adjustment with which you disagree.  
Attach photocopies of supporting information for each issue or adjustment marked. Number the supporting information with the same 
number as its disputed issue. If you need additional blocks, photocopy additional sheets and number accordingly.
1. Disputed issue or adjustment

Reason why you disagree with the audit results

Amount claimed on original return             Amounts allowed on Audit report

2. Disputed issue or adjustment

Reason why you disagree with the audit results

Amount claimed on original return             Amounts allowed on Audit report

3. Disputed issue or adjustment

Reason why you disagree with the audit results

Amount claimed on original return             Amounts allowed on Audit report

                      Do not send original documents — Send photocopies only
                      For Privacy Act Notice see the instructions for your return.
Catalog Number 29360J                         www.irs.gov                                          Form 12661 (Rev. 10-2015)