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INSTRUCTIONS TO PRINTERSFORM 843, PAGE 1 of 2 (Page 2 is Blank.)MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEADPAPER: WHITE WRITING, SUB. 20. INK: BLACKFLAT SIZE: 216mm (8-1/2") x 279mm (11")PERFORATE: None

Form 843OMB No. 1545-0024

Claim for Refund and Request for Abatement(Rev. November 2005)

Department of the TreasuryInternal Revenue Service See separate instructions.

Use Form 843 only if your claim involves (a) one of the taxes shown on line 3a or (b) a refund or abatement of interest, penalties,or additions to tax on line 4a.

Daytime telephone number

Name of claimant

( )

Address (number, street, and room or suite no.)

City or town, state, and ZIP codeTyp

e o

r p

r int

Spouses SSN or ITIN

Your SSN or ITIN

Employer identification number (EIN)

Name and address shown on return if different from above

1 2 Amount to be refunded or abatedPeriod. Prepare a separate Form 843 for each tax period$From / / to / /

Dates of payment b

Type of tax, penalty, or addition to tax:3aEmploymentPenaltyIRC section

GiftEstate

Request for abatement or refund of:4aInterest as a result of IRS errors or delays.A penalty or addition to tax as a result of erroneous advice from the IRS.

Type of return filed (see instructions):709 990-PF 4720945940706

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Form 843 (Rev. 11-2005)Cat. No. 10180R

b

5 Explanation and additional claims. Explain why you believe this claim should be allowed, and show the computation of yourtax refund or abatement of interest, penalty, or addition to tax. If you need more space, attach additional sheets.

Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and, to the best of my knowledge andbelief, it is true, correct, and complete.

DateSignature (Title, if applicable. Claims by corporations must be signed by an officer.)

DateSignature

Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse mustsign the claim. Claims filed by corporations must be signed by a corporate officer authorized to sign, and the signature must beaccompanied by the officers title.

Do not use Form 843 if your claim is for An overpayment of income taxes;

An overpayment of excise taxes reported on Form(s) 11-C, 720, 730, or 2290.

Excise (see instructions)

Other (specify)943941

A refund for nontaxable use (or sales) of fuel; or

f1-1: Your name as is appears on your Form W-2f1-3: f1-4: f1-5: Your local street address in the USf1-6: f1-7: f1-8: f1-9: Your local city, state and zip code in the USf1-11: f1-13: f1-15: 01f1-16: 01f1-17: 05f1-18: 12f1-19: 31f1-20: 05c1-1: Yesc1-2: c1-3: c1-4: c1-5: f1-22: c1-6: c1-7: c1-8: c1-9: c1-10: c1-11: c1-12: c1-13: c1-14: f1-23: c1-15: c1-16: f1-24: f1-24a: ex: EXAMPLE: Refund request for Social Security and/or Medicare taxes withheld in errorf1-25: EXAMPLE:I am a (indicate F-1 or J-1) student who has been in the U.S. less than 5 calendar years and I am considered a nonresident alien for tax purposes. Social Security and Medicare taxes were withheld from my wages while I was on (indicate: Optional Practical Training or Curricular Practical Training). According to IRS Pub. 519, I am not subject to Social Security and Medicare taxes while on Practical Training as long as I am a nonresident alien for tax purposes.

Social Security tax withheld $327Medicare tax withheld $220 ----------Total refund due $547

Note: Social security taxes withheld are reported in box 4 of Form W-2. Medicare taxes withheld are reported in box 6 of form W-2.

sign: Sign your name heredate: Date form signedf1-2: Your Social Security or ITIN #

f1-10: Found in Box b of Form W-2

f1-14: Your local phone number in the US

f1-12: If the name and address on your tax return is different, put it here. Otherwise, leave this area blank.

f1-21: Example: $547