Catalog Number 27779K www.irs.gov
Form
12256 (Rev. 10-2012)
Form 12256
(October 2012)
Department of the Treasury - Internal Revenue Service
Withdrawal of Request for Collection Due Process or Equivalent Hearing
Taxpayer name(s)
Taxpayer address
City State Zip code
Type of tax/tax form*
Tax period(s)*
Social Security/Employer Identification Number(s)*
*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 (IRS) regarding the tax and tax periods that my hearing request concerned
or I am otherwise satisfied that I no longer need a hearing with the Office of Appeals (Appeals). Therefore, I withdraw my hearing
request under (check all that apply):
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
Equivalent Hearing
I understand that by withdrawing my request for a Collection Due Process hearing under Section 6320 and/or 6330:
• I give up my right to a hearing with Appeals. I understand that Appeals will not issue a Notice of Determination with
respect to the tax and tax periods subject to the hearing request. As part of a CDP determination, Appeals verifies
that all legal and administrative requirements were met. I understand that by withdrawing my hearing request,
Appeals will not conduct this verification.
• I give up my right to seek judicial review in the Tax Court of the Notice of Determination that Appeals would have
issued as a result of the CDP Hearing, as Appeals will not issue a Notice of Determination.
• I give up my right to have Appeals retain jurisdiction with respect to any determination that it would have made as a
result of the CDP 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under the provisions of IRC Sections 6320 and 6330, are no longer in effect upon the receipt by the IRS of this
withdrawal.
• I do not give up any other appeal rights that I am entitled to, such as an appeal under the Collection Appeals
Program (CAP).
I understand that by withdrawing my request for an equivalent Hearing:
• I give up my right to a hearing with Appeals. I understand that Appeals will not issue a Decision Letter with respect to the tax and
tax periods subject to the hearing request.
• 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 Date
Spouse's signature (if applicable)
Date
Authorized Representative signature (if applicable)
Date
For privacy Act information please refer to Notice 609
