Catalog Number 40992F www.irs.gov
Form
13711 (Rev. 10-2017)
Form 13711
(October 2017)
Department of the Treasury - Internal Revenue Service
Request for Appeal of Offer in Compromise
Provide the information required in the spaces below. You must sign and date this form.
Taxpayer name Taxpayer Identification Number
Taxpayer name Taxpayer Identification Number
Mailing address
City State ZIP Code
Taxpayer's current daytime telephone number
Tax form number
Tax period(s) ended
Name of authorized representative
Mailing address City State ZIP Code
Telephone number of authorized representative
Best time to call (during normal business hours)
If you disagree with a specific item shown on the Income and Expense Table and Assets and Equity table you received with your
rejection letter, identify the specific item(s). In the space next to the disagreed item, provide a brief statement indicating why you
don't agree with our determination (if the disagreed item is the value of future income, indicate that under "Disagreed Item," and
provide an explanation under "Reason for Disagreement"). There is room for more entries on the back of this form, and you may
use additional pages, if necessary. Attach supporting documents for each disagreed item you identify and indicate on them which
issue they apply to. If you disagree with a reason for the rejection stated in our letter but not discussed on the Table, identify what
statement you disagree with, the reason you disagree and attach any supporting documentation. Additional pages may be
attached. If you do not agree with the Service's analysis of economic hardship or Effective Tax Administration, please provide an
explanation with documentation. If possible, attach a copy of the rejection letter to this form.
Disagreed item
Reason for disagreement (attach supporting documentation)
Certification of Taxpayer: Under penalties of perjury, I declare that to the best of my knowledge, the information contained herein is
true, correct, and complete.
Signature of Taxpayer Date signed Signature of Taxpayer Date signed
Certification for authorized representative: Check the box that applies depending on whether you have personal knowledge.
I declare that I have submitted the protest and accompanying documents and to the best of my
knowledge, the facts stated in the protest and accompanying documents are true, correct, and
complete.
I declare that I have submitted the protest and accompanying documents, but have no
personal knowledge concerning the facts stated in the protest and the accompanying
documents.
Signature of authorized representative (Attach a copy of your completed Form 2848,
Power of Attorney and Declaration of Representative.)
Signature of authorized representative Date signed
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Service employee - Staple the taxpayer's envelope here
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