0322 Form 13369 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f13369.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(March 2022)

Department of the Treasury - Internal Revenue Service

To: IRS Independent Office of Appeals Team Manager Date

Compliance Officer Information (The Person to Contact in Compliance About this Case)

Name Title

Office telephone number (include area code) 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 Telephone number (include area code)

Home street address (p.o. boxes are not allowed)

City State ZIP code

Representative's name Firm name

Office street address (p.o. boxes are not allowed)

City State ZIP code

Office telephone 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 Telephone number (include area code)

Name Position or affiliation Telephone number (include area code)

Name Position or affiliation Telephone number (include area code)

Catalog Number 35327G www.irs.gov Form 13369 (3-2022)

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.

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.

Catalog Number 35327G www.irs.gov Form 13369 (3-2022)