Form 12256 - Withdrawal Of Request For Collection Due Process Hearing
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1Withdrawal of Request for Collection Due Process Hearing
(Please print the information in the spaces below.)
Taxpayer name(s)
Taxpayer address
City
State
ZIP code
*
Type of tax/Tax form number(s)
*
Tax period(s)
*
Social Security Number / Employer Identification Number
*
(Note: You may attach a copy of your Collection Due Process notice to 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 regarding the tax and tax periods that my hearing request
concerned and I'm satisfied that I no longer need a hearing with Appeals. Therefore, I withdraw my request for a
Collection Due Process (CDP) Hearing under:
Internal Revenue Code (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
I understand that by withdrawing my request:
•
I give up my right to a Collection Due Process Hearing with the Office of Appeals. I understand that the Office of
Appeals will not issue a Notice of Determination with respect to the tax and tax periods the hearing request concerned.
•
I give up my right to seek judicial review, in the Tax Court or a U.S. District Court, of the Notice of Determination that
the Office of Appeals would have issued as a result of the Collection Due Process Hearing, as the Office of Appeals
will not issue a Notice of Determination.
•
I give up my right to have the Office of Appeals retain jurisdiction with respect to any determination that it would have
made as a result of the Collection Due Process 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under the provisions of IRC Sections 6320 and 6330, are no longer in effect upon the receipt by Internal Revenue
Service (IRS) of this withdrawal.
•
I have the right to request a hearing with the Office of Appeals that is equivalent to a Collection Due Process Hearing
without judicial appeal to the Tax Court or a U. S. District Court under IRC Section 6320 or 6330.
•
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
Spouse's signature
(if applicable)
Authorized representative's signature
(if applicable)
For Privacy Act information please refer to Notice 609
12256
Department of the Treasury — Internal Revenue Service
publish.no.irs.gov
Form
(6-1999)
Catalog Number 27779K
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