Form 843 Form 843 Claim for Refund and Request for Abatement

Note: The draft you are looking for begins on the next page.

Caution: DRAFT—NOT FOR FILING

This is an early release draft of an IRS tax form, instructions, or publication,
which the IRS is providing for your information. Do not file draft forms and do
not rely on draft forms, instructions, and pubs for filing. We incorporate all
significant changes to forms posted with this coversheet. However, unexpected
issues occasionally arise, or legislation is passed—in this case, we will post a
new draft of the form to alert users that changes were made to the previously
posted draft. Thus, there are never any changes to the last posted draft of a
form and the final revision of the form. Forms and instructions are subject to
OMB approval before they can be officially released, so we post drafts of them
until they are approved. Drafts of instructions and pubs usually have some
additional changes before their final release. Early release drafts are at
IRS.gov/DraftForms and remain there after the final release is posted at
IRS.gov/LatestForms. Also see IRS.gov/Forms.
Most forms and publications have a page on IRS.gov: IRS.gov/Form1040 for
Form 1040; IRS.gov/Pub501 for Pub. 501; IRS.gov/W4 for Form W-4; and
IRS.gov/ScheduleA for Schedule A (Form 1040), for example, and similarly for
other forms, pubs, and schedules for Form 1040. When typing in a link, type it
into the address bar of your browser, not a Search box on IRS.gov.
If you wish, you can submit comments to the IRS about draft or final forms,
instructions, or pubs at IRS.gov/FormsComments. Include “NTF” followed by the
form or pub number (for example, “NTF1040”, “NTFW4”, “NTF501”, etc.) in the
body of the message to route your message properly. We cannot respond to all
comments due to the high volume we receive and may not be able to consider
many suggestions until the subsequent revision of the product, but we will
review each “NTF” message. If you have comments on reducing paperwork and
respondent (filer) burden, with respect to draft or final forms, please respond to
the relevant information collection through the Federal Register process; for
more info, click here.

843

Form
(Rev. December 2024)
Department of the Treasury
Internal Revenue Service

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

Go to www.irs.gov/Form843 for instructions and the latest information.

Check the box below that indicates your reason for filing Form 843.
Tax
Abatement or refund of tax other than income, estate, or gift tax
Abatement or refund of tax that can’t be claimed on any form except Form 843
Refund to employee of excess social security, Medicare, or RRTA tax withheld by any one employer, but only if your employer will
not adjust the overcollection
Refund to employee of excess tier 2 RRTA tax when, for the year, you had more than one railroad employer and your total tier 2
RRTA tax withheld or paid exceeds the tier 2 limit
Refund to employee of social security, Medicare, or RRTA tax withheld in error, but only if your employer will not adjust the
overcollection

TREASURY/IRS
AND OMB USE
ONLY DRAFT
July 2, 2024
DO NOT FILE

Abatement or refund of tier 1 RRTA tax for an employee representative

Penalty
Abatement or refund of a penalty or addition to tax due to reasonable cause or other reason allowed under the law
Refund of penalty imposed under section 6672 for failure to collect and pay over tax, or attempt to evade or defeat tax (Trust Fund
Recovery Penalty)
Refund of penalty imposed under section 6695A for misstatements due to incorrect appraisals
Refund of penalty imposed under section 6715 for misuse of dyed fuel
Abatement or refund under section 6404(f) of a penalty or addition to tax attributable to erroneous written advice by the IRS
Interest
Abatement or refund of interest under section 6404(e)(1)
Request for net interest rate of zero under Rev. Proc. 2000-26
Other
Refund of branded prescription drug fee
Refund of annual fee on health insurance providers
Other (specify)
CAUTION: Do not use Form 843 when you must use a different tax form. For example, do not use Form 843 to claim a refund or
abatement of an overpayment of income taxes or an employer’s claim for FICA tax, RRTA tax, or income tax withholding; 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. Also, do not use Form 843 to claim a refund of tax return preparer or promoter penalties. See instructions for the forms to use.
Name of person requesting refund or abatement (see instructions)

Social security number (SSN)

Name of spouse if filing joint return (see instructions)

Spouse’s social security number (SSN)

Address (number and street or P.O. box if mail is not delivered to street address)

Apt., room, or suite no.

City, town, or post office. If you have a foreign address, also complete spaces below.
Foreign country name

State

ZIP code

Foreign province/state/county

Foreign postal code

Name and address shown on return if different from above

1
2
3

4

Employer ID number (EIN)

Daytime telephone number

Enter the tax period or fee year. Prepare a separate Form 843 for each tax period or fee year.
Beginning date (MM/DD/YYYY)
Ending date (MM/DD/YYYY)
Amount to be refunded or abated. $
Date(s) of payment(s) for which you are requesting a refund (MM/DD/YYYY). If you need more space, attach additional sheets.
a
b
c
d
e
f
g
h
i
j
k
l
Check the box with the type of tax or fee for which you are asking a refund or abatement. Or check the box with the type of tax
or fee to which the interest, penalty, or addition to tax is related. Check only one box.
a

Employment

b

Estate

c

Gift

d

Excise

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

e

Income

f

Cat. No. 10180R

Fee

g

Civil penalty

Form 843 (Rev. 12-2024)

Page 2

Form 843 (Rev. 12-2024)

5

6
7

8

Indicate the type of fee or return, if any, filed to which the tax, interest, penalty, or addition to tax relates.
706
b
709
c
940
d
941
e
943
f
944
g
945
h
990-PF
a
i
1040
j
1120
k
4720
l
CT-2 m
Branded Prescription Drug (BPD) Fee
n
Other (specify)
If the claim or request involves a penalty, enter the Internal Revenue Code (IRC) section on which the penalty is based (see
instructions). IRC section

TREASURY/IRS
AND OMB USE
ONLY DRAFT
July 2, 2024
DO NOT FILE

Check the box that indicates your reason for the request for refund or abatement.
Interest was assessed as a result of IRS errors or delays.
a
b
A penalty or addition to tax was the result of erroneous written advice from the IRS.
c
Reasonable cause or other reason allowed under the law can be shown.
None of the above reasons apply.
d
Explain why you believe this claim or request should be allowed and show how you computed 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 Form
843. Forms 843 filed by corporations must be signed by a corporate officer authorized to sign, and the officer’s title must be included with the
signature. Forms 843 filed by an estate or trust must be signed by the fiduciary.
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.
If the IRS sent you an Identity
Protection PIN, enter it here
(see inst.)
Signature (Title, if applicable. Claims by corporations must be signed by an officer. Claims by an
estate or trust must be signed by the fiduciary.)

Date

Signature (spouse, if joint return)

Date

Paid
Preparer
Use Only

Print/Type preparer’s name

Firm’s name
Firm’s address

Preparer’s signature

If the IRS sent your spouse an
Identity Protection PIN, enter it here
(see inst.)
Date

Check
if
self-employed

PTIN

Firm’s EIN
Phone no.
Form 843 (Rev. 12-2024)