Form 12509 Statement of Disagreement

Best time to Call (January 2005) CHECK HERE IF YOU ALSO WISH TO GO TO APPEALS Daytime phone number Form 12509 Form 12509 (Rev 1 2005) www irs gov Catalog Number 28731A Department of the Treasury Internal Revenue Service I disagree with the Internal Revenue Service determination because My Signature Note: You can use the back of this page or attached additional pages if you need more space Purpose of form: You can use this form to explain why you disagree with the Internal Revenue Service (IRS) Determination concerning relief from joint and several liability for a joint return under Internal Revenue Code sections 6013(e) 6015(b) 6015(c) or 6015(f) in the letter you received with this form Social Security Number Statement of Disagreement Taxpayer Name: Under penalties of perjury I declare that I have examined this statement and to the best of my knowledge and belief it is true correct and complete