COLLECTION DUE PROCESS HEARING REQUEST

[DATE]

Internal Revenue Service — Independent Office of Appeals
[ADDRESS FROM NOTICE]

Re: Request for Collection Due Process Hearing (Form 12153)
Taxpayer: [NAME]
SSN/EIN: [SSN/EIN]
Tax Period(s): [PERIODS]
Notice/Letter No.: [NOTICE NUMBER]

To Whom It May Concern:

I request a Collection Due Process hearing regarding the [Notice of Federal Tax Lien/Final Notice of Intent to Levy] dated [DATE]. I submit Form 12153 and request that collection action be suspended while my appeal is pending.

Issues for Consideration

☐ Collection alternatives (installment agreement, offer in compromise)
☐ Challenge to appropriateness of collection action
☐ Spousal defenses
☐ Other: [SPECIFY]

Proposed Collection Alternative

[DESCRIBE PROPOSED ALTERNATIVE AND SUPPORTING FACTS]

Supporting Documentation

☐ Financial statements
☐ Tax returns
☐ Proof of hardship
☐ Other: [SPECIFY]

Please confirm receipt and advise of the next steps.

Sincerely,

[TAXPAYER NAME]
[ADDRESS]
[PHONE]
[EMAIL]