Template from tincompliance.com. Use this only for a penalty that has already been PAID. The manual says a request is a claim for refund "if the taxpayer requests any amount of overpayment," and that "A request for abatement cannot be retroactively converted to a claim for refund" (IRM 4.10.11.2.1.2(4)-(5), Sept. 4, 2020). A Form 843 on a paid penalty is worked under the claim procedures, "which include an opportunity to appeal if the claim for refund is disallowed" (IRM 4.10.11.6.6.2(3), Sept. 29, 2022); on an unpaid penalty it is an abatement request with "no appeal rights beyond the group level" (IRM 4.23.13.4.1.4(2), July 1, 2024). A valid claim must "Set forth in detail each ground upon which a credit or refund is claimed and facts sufficient to apprise the IRS of the exact basis for the claim," "Specify the amount of the refund requested," and "Reflect the tax type and tax period(s)," and be "signed under penalties of perjury, sent to the correct office as instructed" (IRM 4.10.11.2.1, 4.10.11.2.1.1(1)). Form 843 is for "interest, penalties or additions to tax," not for over-deposited withholding, which goes on Form 945-X (IRM 4.10.11.6.6(1)-(2)). Attach this statement to a completed and signed Form 843; mail to the address in the Form 843 instructions for the penalty or, if a notice gave one, the address on the notice. Delete the bracketed guidance before sending.
[Company legal name]
EIN: [00-0000000]
[Address of record with the IRS]
[Date]
Internal Revenue Service
[Address from the Form 843 instructions, or the address shown on the penalty notice]
Re: Claim for refund of paid penalty; statement in support of Form 843. Taxpayer: [Company legal name], EIN [00-0000000]. Penalty: [IRC 6721 (failure to file correct information returns) / IRC 6722 (failure to furnish correct payee statements) / failure-to-deposit penalty under IRC 6656 on Form 945]. Tax period: [calendar year YYYY]. Notice: [Notice 972CG / CP15 / CP215 / CP 568 / other] dated [date]. Amount claimed: $[amount paid], plus interest paid of $[amount] and statutory interest.
Dear Sir or Madam:
This statement accompanies the enclosed Form 843 and is a claim for refund of a penalty that [Company legal name] has paid in full. [Company] paid $[amount] on [date] by [EFTPS / check number / offset of a refund], as shown on the enclosed proof of payment. [Company] requests refund of that amount, together with any interest paid on it and statutory interest on the overpayment. This is not a request for abatement of an unpaid balance; the penalty has been paid and [Company] asks for the money back.
State the payment date and method and ask for the refund explicitly. The manual classifies the request at filing by "whether the amended return or written request asked for a refund at the time it was filed" (IRM 4.10.11.2.1.2(4)). If a partial payment was made, ask for refund of the amount paid, not only removal of the balance.
1. Tax type and period
Item | Entry |
Type of tax or penalty | [IRC 6721 information-return penalty / IRC 6722 payee-statement penalty / IRC 6656 failure-to-deposit penalty] |
Return the penalty attaches to | [Forms 1099-[NEC / MISC / INT / DIV / K] and Form 1096 or electronic transmittal / Form 945, Annual Return of Withheld Federal Income Tax] |
Tax period | [Calendar year YYYY (information returns due in YYYY+1) / Form 945 for calendar year YYYY] |
Assessment | [Notice number] dated [date]; penalty reference number [PRN, if shown]; assessed $[amount] |
Payment | $[amount] paid [date] by [method]; confirmation or check number [number] |
2. Amount of refund requested
[Company] requests a refund of $[amount], being the full penalty paid[, plus $[amount] of interest paid on the penalty on [date]], with statutory interest from the date of payment. [If partial: [Company] requests a refund of $[amount], being the portion of the penalty attributable to the [number] returns described in section 3, paragraph [x], below.]
The claim amount is the penalty you paid. The manual notes that when "A disputed penalty is the only claim issue," the amount "for letters and waivers is the disputed penalty," while the IRS books the case internally at $1 (Exhibit 4.10.11-6). That $1 is an IRS convention; write the dollar figure you want back.
3. Grounds for the claim, in detail
The penalty should be refunded for the following reasons. Each ground is stated separately with the facts supporting it; the enclosures referenced are listed in section 5.
Ground A. The failures were due to reasonable cause and not to willful neglect.
(i) Significant mitigating factors. [Company] has [filed [number] information returns for [number] years without a penalty / been penalized once before, in [year], on a different failure]. Its compliance history is summarized in Enclosure [n]. [Company] [acted responsibly in seeking to prevent the failure: describe the controls in place before the failure, such as W-9 collection at onboarding, TIN matching before filing, and the annual solicitation calendar].
(ii) Events beyond the filer's control. The failures on the [number] returns listed in Enclosure [n] arose from [the payee's failure to furnish a correct TIN despite solicitation / an action of the IRS or of a third party (name and describe) / a documented system failure on [date] / a natural disaster or other event on [date], describe]. For each payee return, Enclosure [n] shows the date and manner of the initial solicitation, of each annual solicitation, and of each B-Notice mailing, with the payee's response or lack of one.
(iii) Responsible action after the failure. On [date], within [number] days of learning of the failures, [Company] [filed corrected returns for [number] payees / obtained and filed the missing TINs / began backup withholding on the [number] accounts that did not respond / changed the control that failed, describe]. The corrections are listed in Enclosure [n] with filing dates and acknowledgments.
Structure the grounds so an examiner can match each failure to a fact and a document. The manual requires "facts sufficient to apprise the IRS of the exact basis for the claim" (IRM 4.10.11.2.1.1(1)), and a claim that repeats an argument already decided "if no additional facts are submitted" is disallowed without audit (IRM 4.23.13.3.1.1, July 1, 2024). If a 972CG response or a Letter 854-C appeal was already denied on the same facts, add what is new. The "significant mitigating factors" and "events beyond the filer's control" framing follows the reasonable-cause regulation the site's reasonable-cause statement template covers; keep the dates specific.
Ground B. [Alternative or additional ground: the penalty was computed on returns that were filed and correct / on returns filed by another entity under this EIN / at the wrong tier because the corrections were filed by [date] / after the period of limitations on assessment / in duplicate with penalty reference number [PRN] already assessed on [date].]
[State the facts and reference the enclosure that proves them: the electronic filing acknowledgment, the corrected returns with their acknowledgments, the transcript entries, or the earlier notice.]
Ground C. [Delete if not applicable: First Time Abate or other administrative relief was available and not applied. State the qualifying facts.]
4. Request
[Company] asks that the claim be allowed in full and the $[amount] refunded with interest. If the claim is to be disallowed in whole or in part, [Company] asks that the notice state the specific reason for the disallowance and that [Company] be given the opportunity to appeal before any statutory notice of disallowance is issued. [Company] does not waive any right to file suit and does not sign Form 2297 at this time.
IRC 6402(l) requires a stated reason for any disallowance (IRM 4.10.11.2.3(4)). If the IRS does not act within six months you may sue without waiting (IRM 4.23.13.2(2), 4.10.11.2.16.2(1)). Signing Form 2297 starts the two-year period under IRC 6532 (IRM 4.23.13.3.4); Form 3363 (agreed) "does not waive the taxpayer's right to file suit" (IRM 4.23.13.3.5). Letter 917 in reply to a reconsideration request "is not considered a certified notice of claim disallowance" (IRM 4.23.13.6). Answer every request for supporting information; the stock disallowance text is "We are disallowing your claim in full because we did not receive a response to our request for supporting information."
5. Enclosures
☐ Form 843, completed and signed by an authorized officer
☐ Copy of the penalty notice ([number], dated [date]) and of any Letter 854-C, CP15 or CP215 on the same penalty
☐ Proof of payment: EFTPS confirmation, cancelled check or account transcript showing the payment of $[amount] on [date]
☐ Enclosure [n]: schedule of the penalized returns (payee, TIN as filed, amount, failure asserted, correction date)
☐ Enclosure [n]: solicitation log for each payee (initial, annual and B-Notice solicitations, dates, method, response)
☐ Enclosure [n]: electronic filing acknowledgments or certified-mail receipts for the original and corrected returns
☐ Enclosure [n]: compliance history and description of controls
☐ Form 2848 or Form 8821, if a representative signs or is to be contacted
6. Declaration
Under penalties of perjury, I declare that I have examined this claim, including the accompanying Form 843, schedules and statements, and to the best of my knowledge and belief it is true, correct and complete. I am an officer of [Company legal name] authorized to sign on its behalf.
_______________________________________
[Name], [Title]
[Company legal name]
[Phone] | [Email]
Date: ____________________
A claim must be "signed under penalties of perjury" (IRM 4.10.11.2.1, Sept. 4, 2020). Form 843 carries its own jurat; signing both the form and this statement is belt and suspenders. Keep a complete copy and proof of mailing, and calendar two dates: six months from mailing (the no-action right to sue) and the RSED, which for a penalty is at least two years from the payment date (IRM 4.10.11.5.2.3(6) note).
Alternative: informal claim by letter
If Form 843 is unavailable or a letter is preferred, the manual treats a signed letter as an "informal claim" and works it as a claim when it carries the same three elements and asks for the refund (IRM 4.10.11.2.1.1(3)). It warns that "A request for abatement is not an informal claim" (IRM 4.10.11.1.5 note), so the letter must ask for the paid amount back, not for the penalty to be removed. Hand-delivering a claim to an examiner during an open case "may constitute the filing of a claim" (IRM 4.10.11.2.1.3(2)). Use the short form below; attach the same enclosures and the same declaration.
[Company legal name], EIN [00-0000000], [address], [date]
Internal Revenue Service, [address]
Re: Informal claim for refund of paid [IRC 6721 / IRC 6722 / IRC 6656] penalty; [return type]; tax period [calendar year YYYY]; $[amount] paid [date]
This letter is a claim for refund of $[amount], the [IRC 6721 / 6722 / 6656] penalty assessed under [notice number] dated [date] for [return type], tax period [YYYY], which [Company] paid in full on [date] (proof enclosed). The grounds for the claim are: (1) [state each ground in detail with dates, as in section 3 above]; (2) [ground]. The facts supporting each ground and the enclosures proving them are listed on the attached schedule. [Company] requests refund of the full amount with interest and, if the claim is disallowed in whole or in part, a statement of the reason and the opportunity to appeal.
Under penalties of perjury, I declare that I have examined this claim, including the accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct and complete.
_______________________________________
[Name], [Title], [Company legal name], [phone], [email]