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Get and Sign Form Disagreement 2005-2022
APPEALS
Taxpayer Name:
Social Security Number
Statement of Disagreement
I,
, disagree with the Internal Revenue Service determination because
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.
My Signature
Date
Daytime phone number
Best time to Call
Form 12509 (Rev. 1-2005)
www.irs.gov
Catalog Number 28731A
Department of the Treasury-Internal Revenue...
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