Form 12661 — Disputed Issue Verification

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f12661.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(October 2015)

Department of the Treasury - Internal Revenue Service

Taxpayer name

Tax period Social Security Number

Instructions for completing disputed issues

Please complete a separate block for each issue or adjustment with which you disagree.

Attach photocopies of supporting information for each issue or adjustment marked. Number the supporting information with the same number as its disputed issue. If you need additional blocks, photocopy additional sheets and number accordingly.

1. Disputed issue or adjustment

Reason why you disagree with the audit results

Amount claimed on original return Amounts allowed on Audit report

2. Disputed issue or adjustment

Reason why you disagree with the audit results

Amount claimed on original return Amounts allowed on Audit report

3. Disputed issue or adjustment

Reason why you disagree with the audit results

Amount claimed on original return Amounts allowed on Audit report

Do not send original documents — Send photocopies only

For Privacy Act Notice see the instructions for your return.

Catalog Number 29360J www.irs.gov Form 12661 (Rev. 10-2015)