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Federal Free Printable Form 13369 (4-2003) for 2019 Federal Agreement to Mediate

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Agreement to Mediate
Form 13369 (4-2003)

Agreement to Mediate OMB No. 1545-1844 Date To: Appeals Team Manager Compliance Officer Information (The person to contact in Compliance about this case) Name Title Office telephone number ID/Badge number Taxpayer's Identification Number (TIN) Year(s) Source (FE/OE/CO, etc.) MFT Type of Tax (1040, 1120 Emp., etc) or Collection Issue (CDP, OIC etc) Taxpayer's name Phone (Include Area Code) Home street address (P.O. Boxes are not allowed) City State Representative's name Firm name ZIP code Office street address (P.O. Boxes are not allowed) City State ZIP code Office phone number (Include Area Code) FAX number (Include Area Code) IRS and Treasury employees who participate in any way in the mediation process and any person under contract to the IRS invited to participate, will be subject to the confidentiality and disclosure provisions of the Internal Revenue Code, including I.R.C. sections 6103, 7213, 7213A, and 7431. See also 5 U.S.C. section 574. The parties also acknowledge that IRS and all other Treasury employees involved in the mediation are bound by I.R.C. section 7214(a)(8) and must report information concerning violations of any revenue law to the Secretary. The Mediator will have the right to ask either party for additional information if deemed necessary for a full understanding of the issues being mediated. A copy of any submission a party gives to the mediator will be provided simultaneously to the other party. The Taxpayer consents to the disclosure by the IRS of the Taxpayer's returns and return information incident to the mediation to any participant or observer for the Taxpayer, including persons providing expert assistance for the IRS. If the mediation agreement is executed by a person pursuant to a power of attorney executed by the Taxpayer, that power of attorney must clearly express the Taxpayer's grant of authority to consent to disclose the Taxpayer's returns and return information by the IRS to third parties, and a copy of that power of attorney must be attached to this agreement. Taxpayer's signature Date signed Taxpayer's signature Date signed Taxpayer's Representative signature Date signed Compliance Officer's signature Date signed Other Participants (if applicable) Name Position or Affiliation Phone (Include Area Code) Name Position or Affiliation Phone (Include Area Code) Name Position or Affiliation Phone (Include Area Code) Form 13369 (4-2003) Catalog Number 35327G www.irs.gov Department of the Treasury - Internal Revenue Service Privacy and Paperwork Reduction Act Notice The Privacy Act of 1974 requires that when we ask you for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it and whether your response is voluntary, required to obtain a benefit, or mandatory. We are requesting this information under the authority of 26 U.S.C. 7801 and the Restructuring and Reform Act (RRA Section 3468) under Section 7123 of the Internal Revenue Code. The primary purpose of this form is to obtain acknowledgement that you agree to adhere to the mediation rules, agree to the disclosures authorized by you or your representative's signature on the form, and consent to all conditions authorized by the form. Information on this form may be disclosed as authorized by you and section 6103 of the Internal Revenue Code. Providing the information is voluntary. Not providing all or part of the information may preclude or impede participation in the mediation process. We ask for the information on this form to carry out the Internal Revenue laws of the United States. You must give us the information if you wish to participate in the mediation process. You are not required to provide information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax return and return information are confidential, as required by Code section 6103. The time needed to complete this form will vary depending on the circumstances. The estimated average time is 3 minutes. If you have any comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Tax Forms Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. DO NOT send the completed Form 13369 to the Tax Forms Committee. Form 13369 (4-2003) Catalog Number 35327G www.irs.gov Department of the Treasury - Internal Revenue Service
Extracted from PDF file 2018-federal-form-13369.pdf, last modified February 2015

More about the Federal Form 13369 Other TY 2018

We last updated the Agreement to Mediate in February 2019, so this is the latest version of Form 13369, fully updated for tax year 2018. You can download or print current or past-year PDFs of Form 13369 directly from TaxFormFinder. You can print other Federal tax forms here.


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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 13369 from the Internal Revenue Service in February 2019.

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Historical Past-Year Versions of Federal Form 13369

We have a total of four past-year versions of Form 13369 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2018 Form 13369

Form 13369 (4-2003)

2017 Form 13369

Form 13369 (4-2003)

2016 Form 13369

Form 13369 (4-2003)

Agreement to Mediate 2015 Form 13369

Form 13369 (4-2003)


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