0419 Form 12203-A (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f12203a.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(April 2019)

Department of the Treasury - Internal Revenue Service

You must complete the information in the spaces below, including your signature(s) and the date.

Continuing Education Provider name

Program name

Program number(s) Year of review

Mailing address City State ZIP code

Identify the item(s) that you disagree with on Letter 4890 Notice of Denial or on the Summary of Findings Report that you received with the Letter 5015 Notice of Revocation. Tell us why you disagree. You can add more pages if this is not enough space. Please refer to the appropriate Continuing Education Provider Standards in your remarks. CE Provider standard number Reason why you disagree

CE Provider standard number Reason why you disagree

CE Provider standard number Reason why you disagree

CE Provider standard number Reason why you disagree

Signature(s) of Designated Official for Provider

Name Signature Date

Name Signature Date

Purpose of this form: You can use this form to appeal a Letter 4890 Notice of Denial or a Letter 5015 Notice of Revocation of your IRS-approved CE Provider status. You must complete this form in its entirety and attach all supporting information, explanations or documents for the appeal to be considered valid.

Instructions: Upload the completed form through your secure email in your online CE provider account or mail it to the address on the Letter 4890 or Letter 5015. The IRS must receive this form within 30 calendar days of the date of the denial or revocation letter. Once a valid appeal is received, a determination will be made. You will receive a notice that your appeal has either been upheld or overturned.

If you received a Letter 5015 Notice of Revocation and take no action within 30 calendar days, you will be removed from the public listing of IRS approved CE Providers and be prohibited from reinstatement as an approved IRS CE Provider for a period of two years from the date of revocation. Your website should not indicate that you are an approved IRS CE provider nor advertise IRS approved programs. Any outstanding PTIN records not uploaded must be submitted within 10 calendar days.

Catalog Number 68271P www.irs.gov Form 12203-A (Rev. 4-2019)