Form
843
OMB No. 1545-0024
Claim for Refund and Request for Abatement
(Rev. February 2009)
Department of the Treasury
Internal Revenue Service
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See separate instructions.
Use Form 843 if your claim or request involves:
Daytime telephone number
Name(s)
( )
Address (number, street, and room or suite no.)
City or town, state, and ZIP code
Spouse’s social security number
Your social security number
Employer identification number (EIN)
Name and address shown on return if different from above
1
2
Amount to be refunded or abated
Period. Prepare a separate Form 843 for each tax period
$
From / / to / /
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form 843 (Rev. 02-2009)
Cat. No. 10180R
7
Explanation. Explain why you believe this claim or request should be allowed and show the computation of the amount shown
on line 2. If you need more space, attach additional sheets.
Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and, to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Date
Signature (Title, if applicable. Claims by corporations must be signed by an officer.)
Date
Signature (spouse, if joint return)
Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must sign the claim.
Claims filed by corporations must be signed by a corporate officer authorized to sign, and the officer’s title must be shown.
Do not use Form 843 if your claim or request involves:
an overpayment of income taxes or an employer’s claim for FICA tax, RRTA tax, or income tax withholding (use the
appropriate amended tax return),
an overpayment of excise taxes reported on Form(s) 11-C, 720, 730, or 2290.
a refund of excise taxes based on the nontaxable use or sale of fuels, or
a refund of one of the taxes (other than income taxes and an employer’s claim for FICA tax, RRTA tax, or income
tax withholding), shown on line 3,
an abatement of FUTA tax or certain excise taxes, or
(a)
(b)
(c)
a refund or abatement of interest, penalties, or additions to tax for one of the reasons shown on line 5a.
(a)
(b)
(c)
Date(s) of payment(s)
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Type of tax. Indicate the type of tax to be refunded or abated or to which the interest, penalty, or addition to tax is related.
3
Employment
Type of penalty. If the claim or request involves a penalty, enter the Internal Revenue Code section on which the penalty
is based (see instructions). IRC section:
Gift
Estate
4
Interest was assessed as a result of IRS errors or delays.
A penalty or addition to tax was the result of erroneous written advice from the IRS.
709
990-PF
1120
945
940
706
Excise
Other (specify)
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943
Income
Interest, penalties, and additions to tax. Check the box that indicates your reason for the request for refund or
abatement. (If none apply, go to line 6.)
5a
Reasonable cause or other reason allowed under the law (other than erroneous written advice) can be shown for not
assessing a penalty or addition to tax.
b
Original return. Indicate the type of return filed to which the tax, interest, penalty, or addition to tax relates.
6
Preparer’s SSN or PTIN
Date
Preparer’s
signature
Check if
self-employed
Paid
Preparer’s
Use Only
Firm’s name (or
yours if self-employed),
address, and ZIP code
EIN
©
©
Phone no.
( )
941
1040
4720
