Form 843 Form 843 Claim for Refund and Request for Abatement

Attention
Effective August 12, 2013, if you are filing Form 843 in response to Letter
4658 (notice of branded prescription drug fee), note that the Mailstop
number in the Where to File table on page 2 of the Instructions for Form
843 (Rev. December 2012), has changed. The address to mail Form 843 in
this case ONLY is:
Internal Revenue Service
Mailstop 4921
1973 N. Rulon White Blvd.
Ogden, UT 84404
The above mailstop change is effective ONLY if you are filing Form 843 in
response to Letter 4658 (notice of branded prescription drug fee).
Please see the Where to File Table below.

Where To File
IF you are filing Form 843...

THEN mail the form to...

In response to an IRS notice
regarding a tax or fee related to
certain taxes such as income,
employment, gift, estate, excise,
etc.

The address shown in the notice.

For penalties, or for any other
reason other than an IRS notice
(see above) or Letter 4658 (see
below)

The service center where you
would be required to a file a
current year tax return for the tax
to which your claim or request
relates. See the instructions for
the return you are filing.

In response to Letter 4658 (notice
of branded prescription drug fee)
Note. To ensure proper
processing, write "Branded
Prescription Drug Fee" across the
top of Form 843.

Internal Revenue Service
Mail Stop 4921
1973 N. Rulon White Blvd.
Ogden, UT 84404
Caution. Use this address only if
you are claiming a refund of the
branded prescription drug fee.

This change will be reflected in the next revision of the Instructions for
Form 843.

Form

843

Claim for Refund and Request for Abatement
OMB No. 1545-0024

(Rev. August 2011)
Department of the Treasury
Internal Revenue Service

▶

See separate instructions.

Use Form 843 if your claim or request involves:
(a) a refund of one of the taxes (other than income taxes or an employer’s claim for FICA tax, RRTA tax, or income tax
withholding) or a fee, shown on line 3,
(b) an abatement of FUTA tax or certain excise taxes, or
(c) a refund or abatement of interest, penalties, or additions to tax for one of the reasons shown on line 5a.
Do not use Form 843 if your claim or request involves:
(a) an overpayment of income taxes or an employer’s claim for FICA tax, RRTA tax, or income tax withholding (use the
appropriate amended tax return),
(b)
(c)

a refund of excise taxes based on the nontaxable use or sale of fuels, or
an overpayment of excise taxes reported on Form(s) 11-C, 720, 730, or 2290.

Name(s)

Your social security number

Address (number, street, and room or suite no.)

Spouse’s social security number

City or town, state, and ZIP code

Employer identification number (EIN)

Name and address shown on return if different from above

Daytime telephone number

1
3

4
5a

Period. Prepare a separate Form 843 for each tax period or fee year.
2 Amount to be refunded or abated:
From
to
$
Type of tax or fee. Indicate the type of tax or fee to be refunded or abated or to which the interest, penalty, or addition to tax
is related.
Employment
Estate
Gift
Excise
Income
Fee
Type of penalty. If the claim or request involves a penalty, enter the Internal Revenue Code section on which the penalty is
based (see instructions). IRC section:
Interest, penalties, and additions to tax. Check the box that indicates your reason for the request for refund or abatement. (If
none apply, go to line 6.)
Interest was assessed as a result of IRS errors or delays.
A penalty or addition to tax was the result of erroneous written advice from the IRS.
Reasonable cause or other reason allowed under the law (other than erroneous written advice) can be shown for not
assessing a penalty or addition to tax.

b Date(s) of payment(s) ▶
6

7

Original return. Indicate the type of fee or return, if any, filed to which the tax, interest, penalty, or addition to tax relates.
706
709
940
941
943
945
990-PF
1040
1120
4720
Other (specify) ▶
Explanation. Explain why you believe this claim or request should be allowed and show the computation of the amount shown
on line 2. If you need more space, attach additional sheets.

Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must sign the claim.
Claims filed by corporations must be signed by a corporate officer authorized to sign, and the officer’s title must be shown.
Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and, to the best of my knowledge and belief, it is
true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Signature (Title, if applicable. Claims by corporations must be signed by an officer.)

Date

Signature (spouse, if joint return)

Paid
Preparer
Use Only

Date

Print/Type preparer’s name
Firm’s name

Preparer's signature

▶

Firm's address ▶

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Date

Check
if
self-employed

PTIN

Firm's EIN ▶
Phone no.
Cat. No. 10180R

Form 843 (Rev. 8-2011)