15109 Request for Tax Deferment

Form

15109

(November 2017)

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Department of the Treasury - Internal Revenue Service

Request for Tax Deferment

OMB Number
1545-

To be considered for tax deferment, please complete this form and send it to us in the enclosed envelope along with the required
supporting documents by the required date. You can also fax this form to us at 855-233-8562.

Section 1 - Combat Zone Information
Make sure to include dates of entry and exit from your service in any combat zones, contingency operations, or hazardous duty stations
that began or ended during the period(s) on the attached notice. For qualifying areas, refer to Publication 3, Armed Forces Tax Guide,
under the heading Combat Zone Defined.
Your name

SSN

Tax form and year

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Name of organization, employer or military department

Telephone number of organization, employer or military department

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Name of combat zone or other area

Date of entry

Date of exit

Date of entry

Date of exit

Date of entry

Date of exit

Section 2 - Supporting Documentation
If you are a member of the military
• Please include a copy of your military orders showing your deployment dates for the combat zone or contingency operation.
If you are a civilian working for an employer contracted to the federal government
• Please include a copy of your Letter of Authorization.
If you don’t have an authorization letter or military orders
• Please send us a written statement from your employer or the organization for whom you worked. The statement should include
the dates you worked in the designated combat zone area or the hazardous duty station. Do the same for contingency operations.
Please send your information using the stub and envelope provided. You may also fax your response to 855-233-8562.

Catalog Number 69803D

www.irs.gov

Form 15109 (11-2017)

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