Catalog Number 16965S www.irs.gov
911 (Rev. 5-2019)
Instructions for Section I - (Continued from Page 3)
8. Enter the name of the individual we should contact if Section II is not being used. For partnerships, corporations, trusts, etc., enter
the name of the individual authorized to act on the entity's behalf. If the contact person is not the taxpayer or other authorized
individual, please see the Instructions for Section II.
9a. Enter your daytime telephone number, including the area code. If this is a cell phone number, please check the box.
9b. If you have an answering machine or voice mail at this number and you consent to TAS leaving confidential information about your
tax issue at this number, please check the box. You are not obligated to have information about your tax issue left at this number. If
other individuals have access to the answering machine or the voice mail and you do not wish for them to receive any confidential
information about your tax issue, please do not check the box.
10. Indicate the best time to call you. Please specify A.M. or P.M. hours.
11. Indicate any special communication needs
(such as sign language). Specify any language other than English.
12a. Please describe the tax issue you are experiencing and any difficulties it may be creating. Specify the actions that the IRS has
taken (or not taken) to resolve the issue. If the issue involves an IRS delay of more than 30 days in resolving your issue, indicate
the date you first contacted the IRS for assistance. See Section III for a specific list of TAS criteria.
12b. Please describe the relief/assistance you are requesting. Specify the action you want taken and believe necessary to resolve the
issue. Furnish any documentation you believe would assist us in resolving the issue.
13-14. If this is a joint assistance request, both spouses must sign and date the request. If only one spouse is requesting assistance,
only that spouse must sign the request. If this request is being submitted for another individual, only a person authorized and
empowered to act on that individual's behalf should sign the request. Requests for corporations must be signed by an officer
and include the officer's title.
Note: The signing of this request allows the IRS by law to suspend any applicable statutory periods of limitation relating to the
assessment or collection of taxes. However, it does not suspend any applicable periods for you to perform acts related to assessment
or collection, such as petitioning the Tax Court for redetermination of a deficiency or requesting a Collection Due Process hearing.
Instructions for Section II
Taxpayers: If you wish to have a representative act on your behalf, you must give him/her power of attorney or tax information
authorization for the tax return(s) and period(s) involved. For additional information see Form 2848, Power of Attorney and Declaration
of Representative, or Form 8821, Tax Information Authorization, and the accompanying instructions.
Representatives: If you are an authorized representative submitting this request on behalf of the taxpayer identified in Section I,
complete Blocks 1 through 7 of Section II. Attach a copy of Form 2848, Form 8821, or other power of attorney. Enter your Centralized
Authorization File (CAF) number in Block 2 of Section II. The CAF number is the unique number that the IRS assigns to a
representative after Form 2848 or Form 8821 is filed with an IRS office.
Note: Form 8821 does not authorize your appointee to advocate your position with respect to the Federal tax laws; to execute waivers,
consents, or closing agreements; or to otherwise represent you before the IRS. Form 8821 does authorize anyone you designate to
inspect and/or receive your confidential tax information in any office of the IRS, for the type of tax and tax periods you list on
Instructions for Section III (For IRS Use Only) Please complete this section in its entirety.
Enter the taxpayer's name and taxpayer identification number from the first page of this form.
1. Enter your name.
2. Enter your phone number.
3a. Enter your Function (e.g., ACS, Collection, Examination, Customer Service, etc.).
3b. Enter your Operating Division (W&I, SB/SE, LB&I, or TE/GE).
4. Enter the Organization code number for your office (e.g., 18 for AUSC, 95 for Los Angeles).
5. Check the appropriate box that best reflects how the need for TAS assistance was identified. For example, did taxpayer or
representative call or write to an IRS function or TAS.
6. Enter the date the taxpayer or representative called or visited an IRS office to request TAS assistance. Or enter the date when the
IRS received the Congressional correspondence/inquiry or a written request for TAS assistance from the taxpayer or representative.
If the IRS identified the taxpayer's issue as meeting TAS criteria, enter the date this determination was made.
7. Check the box that best describes the reason TAS assistance is requested. Box 9 is for TAS Use Only.
8. State the action(s) you took to help resolve the taxpayer's issue. State the reason(s) that prevented you from resolving the
taxpayer's issue. For example, levy proceeds cannot be returned because they were already applied to a valid liability; an
overpayment cannot be refunded because the statutory period for issuing a refund expired; or current law precludes a specific
9. Provide a description of the taxpayer's situation, and where appropriate, explain the circumstances that are creating the economic
burden and how the taxpayer could be adversely affected if the requested assistance is not provided.
10. Ask the taxpayer how he or she learned about the TAS and indicate the response here.