Instructions
Please complete all blocks. Write "NONE" if the block does not apply.
Use this form only for reimbursement of bank charges for:
Records to support your claim must include bank, statements and
correspondence.
1. an erroneous levy, or
2. stopping payment on a check that the IRS lost or misplaced.
If you have any questions about this claim, please contact the IRS
office that issued the levy or requested replacement of your
The claimant must sign this form. However, an authorized agent
check. The address is on your copy of the levy or the request for
or legal representative can file and sign the claim if the claimant
a new check.
can't because of disability, death, or other acceptable reason.
Include proof of authorization if the claim is being filed on behalf
If IRS approves your claim, the money can be sent to your bank by
of someone.
electronic funds transfer
, or we can send you a check. If you
(EFT)
want us to pay your claim by EFT, we need the bank information in
Claims must be made within one year of the date the claim
items 6 through 10. The American Bankers Association
(ABA)
accrues and are limited to $1,000. (See 31 USC 3723)
number
is the first nine digits in the number at the bottom of
(item 7)
your checks. If you have no checking account, ask your bank what
Please attach verification of the amount you are claiming. Include
its ABA number is. If you do not complete items 6 through 10, a
any documentation you may have explaining or acknowledging
check will be sent to you.
the IRS' error. Also, include:
1. a copy of the levy (if the charges were caused by an
erroneous levy),
2. records showing the bank charges caused by the erroneous
levy or the request for replacement of a lost or misplaced
check, and
3. records showing that the bank charges have been paid.
Internal Revenue Policy P-5-39
Reimbursement of Bank Charges Due to Erroneous Levy and
Service Loss or Misplacement of Taxpayer Checks
The Service recognizes that there are circumstances when an
The following criteria must be present in all erroneous levy
erroneous use of its unique enforcement powers may cause tax-
cases:
payers to incur certain bank charges. Taxpayers who incur bank
(1) The Service acknowledges the levy was erroneous;
charges due to an erroneous levy may file a claim for reimburse-
(2) The taxpayers must not have contributed to the continuation
ment of those expenses. Bank charges include a financial institu-
or compounding of the error; and
(3) Prior to the levy, the taxpayer did not refuse (either orally or
tion's customary charge for complying with the levy instructions
and charges for overdrafts that are a direct consequence of an
in writing) to timely respond to Service inquiries or provide infor-
erroneous levy. In addition, there are times when a taxpayer's
mation relevant to the liability for which the levy was made.
The following criteria must be present in all lost check cases:
check may be lost or misplaced in processing. When the Service
asks for a replacement check, the taxpayer maybe reimbursed
(1) The Service acknowledges it lost or misplaced the check
for bank charges incurred in stopping payment on the original
during processing;
(2) the Service asks the taxpayer for a replacement of the pay-
check. The charges must have been paid by the taxpayer and
must not have been waived or reimbursed by the financial institu-
ment; and
tion. Claims must be filed with the District Director or Service
(3) the Service is satisfied that the replacement payment has
Center Director within one year after accrual of the expense.
been received.
In compliance with the Privacy Act of 1974, the following is provided.
Solicitation of the information is authorized by Title 31 USC
claim. We may disclose the information on this form relevant to
3723; 31 CFR 3.20 et seq. Disclosure of the information is
the processing of your claim or to any court proceedings resulting
from your claim. We may give the information to the Department
voluntary.
of Justice for the purpose of seeking legal advice or recommend-
The principal purpose of this information will be for our internal
ing prosecutions for fraudulent claims or the making of false
statements.
use in processing your claim under 31 USC 3723, or for any
court proceedings which may ensue from the filing of this
8546
Form
(Rev. 2-2001)