Agreement to Mediate

• Legal Form Number: 13369
• Year: 2022
• Issuer: Treasury Department
• Section: Treasury Department

Catalog Number 35327Gwww.irs.govForm 13369 (3-2022)

Form 13369

(March 2022)

Department of the Treasury - Internal Revenue Service

Agreement to Mediate

To: IRS Independent Office of Appeals Team ManagerDate

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 nameTelephone number (include area code)

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

CityStateZIP code

Representative's nameFirm name

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

CityStateZIP 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 signatureDate signed

Taxpayer's signatureDate signed

Taxpayer's Representative signatureDate signed

Compliance Officer's signatureDate signed

Other Participants (If Applicable)

NamePosition or affiliationTelephone number (include area code)

NamePosition or affiliationTelephone number (include area code)

NamePosition or affiliationTelephone number (include area code)