Catalog Number 68271P www.irs.gov
Form
12203-A (9-2015)
Form 12203-A
(September 2015)
Department of the Treasury - Internal Revenue Service
Request for Appeal
You must complete the information in the spaces below, including your signature(s) and the date.
Continuing Education Provider name
Program name
Program number(s) Year of review
Mailing address City State ZIP code
Identify the item(s) that you disagree with on Letter 4890 Notice of Denial or on the Summary of Findings Report that you received with
the Letter 5015 Notice of Revocation. Tell us why you disagree. You can add more pages if this is not enough space. Please refer to
the appropriate Continuing Education Provider Standards in your remarks.
CE Provider standard number Reason why you disagree
CE Provider standard number Reason why you disagree
CE Provider standard number Reason why you disagree
CE Provider standard number Reason why you disagree
Signature(s) of Designated Official for Provider
Name Signature Date
Name Signature Date
Name and signature of authorized representative (If a representative is signing this form, please attach a copy of your completed
Form 2848, Power of Attorney and Declaration of Representative.)
Name Signature Date
Your telephone number Best time to call
click to sign
signature
click to edit
click to sign
signature
click to edit
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
click to sign
signature
click to edit
Page 2
Catalog Number 68271P www.irs.gov
Form
12203-A (9-2015)
Purpose of this form: You can use this form to appeal a Letter 4890 Notice of Denial or a Letter 5015 Notice of Revocation of your
IRS-approved CE Provider status. You must complete this form in its entirety and attach all supporting information, explanations or
documents for the appeal to be considered valid.
Instructions: Upload the completed form through your secure email in your online CE provider account or mail it to the address on the
Letter 4890 or Letter 5015. The IRS must receive this form within 30 calendar days of the date of the denial or revocation letter. Once a
valid appeal is received, a determination will be made. You will receive a notice that your appeal has either been upheld or overturned.
If you received a Letter 5015 Notice of Revocation and take no action within 30 calendar days, you will be removed from the public
listing of IRS approved CE Providers and be prohibited from reinstatement as an approved IRS CE Provider for a period of two years
from the date of revocation. Your website should not indicate that you are an approved IRS CE provider nor advertise IRS approved
programs. Any outstanding PTIN records not uploaded must be submitted within 10 calendar days.
Privacy Act and Paperwork Reduction Notice
We ask for the information on this form to carry out the laws of the United States. We need it to ensure that continuing education providers are
complying with these laws. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless
the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may
become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Internal
Revenue Code section 6103. The time require to complete this form will vary depending on individual circumstances. The estimated average time is 15
minutes.
The primary purpose of this form is to report potential violations of the law by continuing education providers. We are requesting this information under
authority of 26 U.S.C. § 7801 and § 7803 and 31 U.S.C. § 330. Providing this information is voluntary, and failure to provide all or part of the information
will not affect you. Providing false or fraudulent information may subject you to penalties. We may disclose this information to the Department of Justice
to enforce the tax laws, both civil and criminal, and to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out 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, and to federal law enforcement and intelligence agencies to combat terrorism.
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