Form 12153 - Request For A Collection Due Process Or Equivalent Hearing
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412153
Form
Request for a Collection Due Process or Equivalent Hearing
(Rev. 12-2013)
Use this form to request a Collection Due Process (CDP) or equivalent hearing with the IRS Office of
Appeals if you have been issued one of the following lien or levy notices:
• Notice of Federal Tax Lien Filing and Your Right to a Hearing under IRC 6320,
• Notice of Intent to Levy and Notice of Your Right to a Hearing,
• Notice of Jeopardy Levy and Right of Appeal,
• Notice of Levy on Your State Tax Refund,
• Notice of Levy and Notice of Your Right to a Hearing.
Complete this form and send it to the address shown on your lien or levy notice. Include a copy
of your lien or levy notice to ensure proper handling of your request.
Call the phone number on the notice or 1-800-829-1040 if you are not sure about the correct address
or if you want to fax your request.
You can find a section explaining the deadline for requesting a Collection Due Process
hearing in this form's instructions. If you've missed the deadline for requesting a CDP
hearing, you must check line 7 (Equivalent Hearing) to request an equivalent hearing.
1. Taxpayer Name: (Taxpayer 1)
Taxpayer Identification Number
Current Address
City
State
Zip Code
-
2.
Telephone Number and Best Time
(
)
am.
pm.
Home
to Call During Normal Business
-
(
)
am.
pm.
Work
Hours
-
am.
pm.
(
)
Cell
3. Taxpayer Name: (Taxpayer 2)
Taxpayer Identification Number
Current Address
(If Different from
City
State
Zip Code
Address Above)
-
4.
Telephone Number and Best Time
(
)
am.
pm.
Home
to Call During Normal Business
-
(
)
am.
pm.
Work
Hours
-
am.
pm.
(
)
Cell
5. Tax Information as Shown on the Lien or Levy Notice (
)
If possible, attach a copy of the notice
Type of Tax (Income,
Tax Form Number
Employment, Excise,
Tax Period or Periods
(1040, 941, 720, etc)
etc. or Civil Penalty)
12153
Form
(Rev. 12-2013)
Catalog Number 26685D
Department of the Treasury - Internal Revenue Service
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