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Department of the Treasury - Internal Revenue Service Form 13711 (October 2017) Request for Appeal of Offer in Compromise Provide the information required in the spaces below. You must sign and date this form. Taxpayer name Taxpayer Identification Number Taxpayer name Taxpayer Identification Number Mailing address Tax form number City State ZIP Code Tax period(s) ended Taxpayer's current daytime telephone number Service employee - Staple the taxpayer's envelope here Name of authorized representative Mailing address City State ZIP Code Telephone number of authorized representative Best time to call (during normal business hours) If you disagree with a specific item shown on the Income and Expense Table and Assets and Equity table you received with your rejection letter, identify the specific item(s). In the space next to the disagreed item, provide a brief statement indicating why you don't agree with our determination (if the disagreed item is the value of future income, indicate that under "Disagreed Item," and provide an explanation under "Reason for Disagreement"). There is room for more entries on the back of this form, and you may use additional pages, if necessary. Attach supporting documents for each disagreed item you identify and indicate on them which issue they apply to. If you disagree with a reason for the rejection stated in our letter but not discussed on the Table, identify what statement you disagree with, the reason you disagree and attach any supporting documentation. Additional pages may be attached. If you do not agree with the Service's analysis of economic hardship or Effective Tax Administration, please provide an explanation with documentation. If possible, attach a copy of the rejection letter to this form. Disagreed item Reason for disagreement (attach supporting documentation) Certification of Taxpayer: Under penalties of perjury, I declare that to the best of my knowledge, the information contained herein is true, correct, and complete. Signature of Taxpayer Date signed Signature of Taxpayer Date signed Certification for authorized representative: Check the box that applies depending on whether you have personal knowledge. I declare that I have submitted the protest and accompanying documents and to the best of my knowledge, the facts stated in the protest and accompanying documents are true, correct, and Scan this QR Code with complete. your smartphone or I declare that I have submitted the protest and accompanying documents, but have no other device with a QR personal knowledge concerning the facts stated in the protest and the accompanying reader, or go to the documents. website url shown, to Signature of authorized representative (Attach a copy of your completed Form 2848, view more information Power of Attorney and Declaration of Representative.) about completing this form and other Appeals Signature of authorized representative Date signed www.irs.gov/appeals processes online. Catalog Number 40992F www.irs.gov Form 13711 (Rev. 10-2017)
