Form 14017 (Rev. 10-2010)
Catalog Number 51767Y
Application for Fast Track Settlement
www.irs.gov
Taxpayer Signature Date signed
Submitted to Appeals
LB&I SB/SE TE/GE Other
Taxpayer name
Taxpayer TIN/EIN
Address
City State Zip
Telephone Fax
Address
City State Zip
Telephone Fax
Representative name (If applicable)
Name of Firm
City State Zip Telephone Fax
Examination Group / Team Manager
Tax years
Signatures
The undersigned request Appeals assistance in the Fast Track Settlement (FTS) process. The issues for which this assistance is requested are
described in the Form(s) 5701, Summary of Issues or Examination Re-Engineering Lead Sheets or similar documents and the taxpayer’s written
response, and are attached to this application. By signing this application, taxpayer consents, pursuant to section 6103(c) of the Code, to the disclosure
of the taxpayer’s returns and return information pertaining to the issues being considered in the FTS process to those persons named on the application
as participants in the process. The prohibition against ex parte communications between Appeals personnel and other Service employees provided by
section 1001(a) of the Internal Revenue Service Restructuring and Reform Act of 1998 does not apply to the communications arising in FTS because
Appeals personnel, in facilitating an agreement between the taxpayer and the other Service Operating Division, are not acting in their traditional Appeals
settlement role. IRS employees, taxpayer and persons invited to participate by the IRS or taxpayer will not voluntarily disclose information regarding any
communication made during the FTS session, except as provided by statute.
Yes No
Coordinated Industry Case (CIC)
Potential Joint Committee
Listed Transaction Yes No
Fast Track End Date
Industry (IC)
NRIndustry HMT RFPH CTM
Preferred Conference Site
Department of the Treasury - Internal Revenue Service
Other
FS
MFT: PBC:
From
Type of Tax
Source (FE/OE/CO, etc)
Other Participants (if applicable)
Name Position or Affiliation Phone
Date Location
Taxpayer Spouse's Signature (If related to a joint return)
Date signed
Taxpayer(s) Representative Signature
Date signed
IRS Group / Team Manager Signature
Date signed
Approving Operating Division Official (Signature and Title)
Date signed
Accepted by Appeals Official (Appeals Team Manager Signature)
Date signed
Accepted by Appeals Official (Appeals Program Manager Signature)
Date signed
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