Form 12277
(October 2011)
Department of the Treasury — Internal Revenue Service
Application for Withdrawal of Filed
Form 668(Y), Notice of Federal Tax Lien
(Internal Revenue Code Section 6323(j))
1. Taxpayer Name
(as shown on the Notice of Federal Tax Lien) 2. Social Security/Employer Identification No.
3. Taxpayer's Representative, if applicable, or Name and Title of contact person, if taxpayer is a business
4. Address
(Number, Street, P.O. Box)
5. City 6. State 7. ZIP code 8. Phone Number
9. Attach copy of the Form 668(Y), Notice of Federal Tax Lien, if available, OR, if you don't have a copy, provide the
following information, if available:
Serial number of Form 668(Y)
(found near the top of the document) Date Form 668(Y) filed
Recording office where Form 668(Y) was filed
10. Current status of the federal tax lien
("x" appropriate box)
Open Released Unknown
11. Reason for requesting withdrawal of the filed Notice of Federal Tax Lien
("x" appropriate box(es))
The Notice of Federal Tax Lien was filed prematurely or not in accordance with IRS procedures.
The taxpayer entered into an installment agreement to satisfy the liability for which the lien was imposed
and the agreement did not provide for a Notice of Federal Tax Lien to be filed.
The taxpayer is under a Direct Debit Installment Agreement.
Withdrawal will facilitate collection of the tax.
The taxpayer, or the Taxpayer Advocate acting on behalf of the taxpayer, believes withdrawal is in the
best interest of the taxpayer and the government.
12. Explain the basis for the withdrawal request
(attach additional sheets and other documentation that substantiates your
request, as needed)
Affirmation
Under penalties of perjury, I declare that I have examined this application (including any accompanying
schedules, exhibits, affidavits, and statements) and, to the best of my knowledge and belief, it is true,
correct, and complete
Signature (Taxpayer or Representative)
Title (if business) Date
Catalog Number 27939C
www.irs.gov
Form
12277 (Rev. 10-2011)
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General Instructions
1.
Complete the application. If the information you supply is
not complete, it may be necessary for the IRS to obtain
additional information before making a determination on the
application.
Sections 1 and 2: Enter the taxpayer's name and
Social Security Number (SSN) or Employer
Identification Number (EIN) as shown on the Notice of
Federal Tax Lien (NFTL).
Section 3: Enter the name of the person completing
the application if it differs from the taxpayer's name in
section 1 (for example, taxpayer representative). For
business taxpayers, enter the name and title of person
making the application. Otherwise, leave blank.
Sections 4 through 8: Enter current contact information
of taxpayer or representative.
Section 9: Attach a copy of the NFTL to be withdrawn,
if available. If you don't have a copy of the NFTL but
have other information about the NFTL, enter that
information to assist the IRS in processing your
request.
Section 10: Check the box that indicates the current
status of the lien.
"Open" means there is still a balance owed with
respect to the tax liabilities listed on the NFTL.
"Released" means the lien has been satisfied or is no
longer enforceable.
"Unknown" means you do not know the current status
of the lien.
Section 11: Check the box(es) that best describe the
reason(s) for the withdrawal request. NOTE: If you are
requesting a withdrawal of a released NFTL, you
generally should check the last box regarding the best
interest provision.
Section 12: Provide a detailed explanation of the
events or the situation to support your reason(s) for the
withdrawal request. Attach additional sheets and
supporting documentation, as needed.
Affirmation: Sign and date the application. If you are
completing the application for a business taxpayer,
enter your title in the business.
2.
Mail your application to the IRS office assigned your
account. If the account is not assigned or you are
uncertain where it is assigned, mail your application to IRS,
ATTN: Advisory Group Manager, in the area where you live
or is the taxpayer's principal place of business. Use
Publication 4235, Advisory Group Addresses, to determine
the appropriate office.
3.
Your application will be reviewed and, if needed, you may
be asked to provide additional information. You will be
contacted regarding a determination on your application.
a. If a determination is made to withdraw the NFTL, we
will file a Form 10916(c), Withdrawal of Filed Notice of
Federal Tax Lien, in the recording office where the
original NFTL was filed and provide you a copy of the
document for your records.
b. If the determination is made to not withdraw the
NFTL, we will notify you and provide information
regarding your rights to appeal the decision.
4.
At your request, we will notify other interested parties
of the withdrawal notice. Your request must be in
writing and provide the names and addresses of the
credit reporting agencies, financial institutions, and/or
creditors that you want notified.
NOTE: Your request serves as our authority to release the
notice of withdrawal information to the agencies, financial
institutions, or creditors you have identified.
5.
If, at a later date, additional copies of the withdrawal notice
are needed, you must provide a written request to the
Advisory Group Manager. The request must provide:
a. The taxpayer's name, current address, and taxpayer
identification number with a brief statement
authorizing the additional notifications;.
b. A copy of the notice of withdrawal, if available; and
c. A supplemental list of the names and addresses of
any credit reporting agencies, financial institutions, or
creditors to notify of the withdrawal of the filed Form
668(Y).
.
Privacy Act Notice
We ask for the information on this form to carry out the
Internal Revenue laws of the United States. The primary
purpose of this form is to apply for withdrawal of a notice of
federal tax lien. The information requested on this form is
needed to process your application and to determine
whether the notice of federal tax lien can be withdrawn.
You are not required to apply for a withdrawal; however, if
you want the notice of federal tax lien to be withdrawn, you
are required to provide the information requested on this
form. Sections 6001, 6011, and 6323 of the Internal
Revenue Code authorize us to collect this information.
Section 6109 requires you to provide the requested
identification numbers. Failure to provide this information
may delay or prevent processing your application; providing
false or fraudulent information may subject you to penalties.
Routine uses of this information include giving it to the
Department of Justice for civil and criminal litigation, and to
cities, states, the District of Columbia, and U.S.
commonwealths and possessions for use in administering
their tax laws. We may also disclose this information to
other countries under a tax treaty, to federal and state
agencies to enforce federal nontax criminal laws, or to
federal law enforcement and intelligence agencies to
combat terrorism.
Catalog Number 27939C
www.irs.gov
Form
12277 (Rev. 10-2011)
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