Catalog Number 29360J www.irs.gov
Form
12661 (Rev. 10-2015)
Form 12661
(October 2015)
Department of the Treasury - Internal Revenue Service
Disputed Issue Verification
Taxpayer name
Tax period Social Security Number
Instructions for completing disputed issues
Please complete a separate block for each issue or adjustment with which you disagree.
Attach photocopies of supporting information for each issue or adjustment marked. Number the supporting information with the same
number as its disputed issue. If you need additional blocks, photocopy additional sheets and number accordingly.
1. Disputed issue or adjustment
Reason why you disagree with the audit results
Amount claimed on original return Amounts allowed on Audit report
2. Disputed issue or adjustment
Reason why you disagree with the audit results
Amount claimed on original return Amounts allowed on Audit report
3. Disputed issue or adjustment
Reason why you disagree with the audit results
Amount claimed on original return Amounts allowed on Audit report
Do not send original documents — Send photocopies only
For Privacy Act Notice see the instructions for your return.