Tax Claim Exclusion

TAX CLAIM EXCLUSION

This Tax Claim Exclusion is submitted by the taxpayer named below to request exclusion of a specified tax claim or assessment from collection, offset, or administrative claim action. Completion of this form constitutes a written request and a certification by the signer under penalties of perjury as set forth in the Certification section of this form.

Taxpayer Identification

Entity Type

Select the entity type that best describes the taxpayer submitting this request:

Taxpayer Identification Number (TIN)

Provide either your Social Security Number (SSN) or Employer Identification Number (EIN). Do not enter both unless both apply.

Claim Information

Assessment Date:

Tax Period Covered (From):

Tax Period Covered (To):

Grounds for Exclusion

Check all grounds that apply to this request. For any ground selected, provide an explanation and attach supporting documentation as indicated below.

Certification and Authorization

By signing below, the taxpayer certifies under penalties of perjury that the statements made on this form are true, correct, and complete to the best of the signer's knowledge and belief. The signer further acknowledges and agrees to the numbered statements below:

1. I am authorized to submit this Tax Claim Exclusion on behalf of the taxpayer identified above and have provided truthful and accurate information in support of this request.

2. I understand that knowingly making a false statement or submitting false documents in connection with this request may subject the signer to civil and criminal penalties, including penalties for perjury.

3. I authorize the taxing authority to contact me or my authorized representative to request additional information or documentation necessary to review this request.

4. I request that the taxing authority exclude the identified claim from collection, offset, or other administrative action pending review and resolution consistent with applicable law.

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