1217 Form 13711 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f13711.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(December 2017)

Department of the Treasury - Internal Revenue Service

Provide the information required in the spaces below. You must sign and date this form.

Taxpayer name Taxpayer Identification Number

Taxpayer name Taxpayer Identification Number

Mailing address

City State ZIP Code

Taxpayer's current daytime telephone number

Name of authorized representative

Tax form number

Tax period(s) ended

Mailing address City State ZIP Code

Telephone number of authorized representative Best time to call (during normal business hours)

If you disagree with a specific item shown on the Income and Expense Table and Assets and Equity table you received with your rejection letter, identify the specific item(s). In the space next to the disagreed item, provide a brief statement indicating why you don't agree with our determination (if the disagreed item is the value of future income, indicate that under "Disagreed Item," and provide an explanation under "Reason for Disagreement") . There is room for more entries on the back of this form, and you may use additional pages, if necessary. Attach supporting documents for each disagreed item you identify and indicate on them which issue they apply to. If you disagree with a reason for the rejection stated in our letter but not discussed on the Table, identify what statement you disagree with, the reason you disagree and attach any supporting documentation. Additional pages may be attached. If you do not agree with the Service's analysis of economic hardship or Effective Tax Administration, please provide an explanation with documentation. If possible, attach a copy of the rejection letter to this form.

Disagreed item Reason for disagreement (attach supporting documentation)

Certification of Taxpayer: Under penalties of perjury, I declare that to the best of my knowledge, the information contained herein is true, correct, and complete.

Signature of Taxpayer Date signed Signature of Taxpayer Date signed

Certification for authorized representative: Check the box that applies depending on whether you have personal knowledge.

I declare that I have submitted the protest and accompanying documents and to the best of my knowledge, the facts stated in the protest and accompanying documents are true, correct, and complete.

I declare that I have submitted the protest and accompanying documents, but have no personal knowledge concerning the facts stated in the protest and the accompanying documents.

Signature of authorized representative (Attach a copy of your completed Form 2848, Power of Attorney and Declaration of Representative.)

Signature of authorized representative Date signed

www.irs.gov/compliance/appeals

Scan this QR Code with your smartphone or other device with a QR reader, or go to the website url shown, to view more information about completing this form and other Appeals processes online.

Catalog Number 40992F www.irs.gov Form 13711 (Rev. 12-2017)

Disagreed item Reason for disagreement (attach supporting documentation)

Disagreed item Reason for disagreement (attach supporting documentation)

Disagreed item Reason for disagreement (attach supporting documentation)

Disagreed item Reason for disagreement (attach supporting documentation)

Disagreed item Reason for disagreement (attach supporting documentation)

Disagreed item Reason for disagreement (attach supporting documentation)

Disagreed item Reason for disagreement (attach supporting documentation)

Disagreed item Reason for disagreement (attach supporting documentation)

Catalog Number 40992F www.irs.gov Form 13711 (Rev. 12-2017)