Form 13369 Agreement to Mediate

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