Use this exhibit to identify the Primary Business Code (PBC), Filing Location Code (FLC) and the Employee Group Code (EGC) on an IDRS TXMODA screen.

Assessments originating in the Campuses will be sent back to that campus. Refer to the Filing Location Code (FLC) and Employee Group Code (EGC)to determine the Campus where the assessment originated.

Assessments made by the Area Office are sent to SB/SE based on back end state mapping.

For more information refer to 4.13.2.2(4).

Contact the Appeals Account Resolution Specialist in Fresno at (559) 456–5931 to find out who worked the case in Appeals.

The originating campus may be determined from the address in the upper left corner of the CP2000 (if available) or from the first two digits of the TC922 DLN. Send the request to the Campus where the assessment originated.

This Form 12249 is prepared using the fields indicated, and outlined in Exhibit 4.13.8.

This screen print of an ADJ54 screen identifies the fields that are optional or that need to be entered. Exhibit 4.13.10 provides the valid entries for each field.

This sheet should be prepared for each Audit Reconsideration received and worked by the first read examiner.

Don't automatically send audit reconsideration requests on closed Appeals cases to Appeals. Some reconsideration requests should go to Appeals. Some should be routed to the originating function that made the adjustment – AUR, ASFR, Exam, etc. Some must be rejected because the Appeals closure was final. It depends on how Appeals closed the case.

C] MARRIED FILING SEPARATE RETURN
1. Please furnish your spouse’s full name, current address, and social security number.

D] HEAD OF HOUSEHOLD
1. If you were divorced or legally separated, send a complete copy of divorce decree or separation agreement, including any modifications.
2. Send copies of cancelled checks and receipts for the qualifying person’s expenses such as mortgage payments rent, utilities, repairs, insurance, food, clothing and other personal expenses.
3. Send records to show who paid or contributed toward the support of the qualifying person(s) and the amount contributed by each person involved, including amounts received from governmental agencies such as food stamps or any payments made by any social service agency.
4. Send copies of school records, driver’s license and medical bills for the qualifying person to verify his or her place of residence.

E] QUALIFYING CHILD FOR EARNED INCOME CREDIT
1. Send a copy of the social security card for each qualifying child.
2. Send a copy of the official birth certificate for each qualifying dependent.
3. List all persons living with you in the same household for the calendar year. Include the name, social security number, relationship to you and the number of months each person lived with you.
4. Send copies of the records to show your dependent’s place of residence for the year. These records must be official, must show the name and residence address of each qualifying dependent, and must show specific residence dates during the calendar year.
5. Send a copy of the doctor’s statement if your qualifying child is totally and permanently disabled.

F] DEPENDENTS WHO LIVE WITH YOU
1. Send a computation of the total cost of support for each dependent living with you.
2. Send a computation of the amount of income or other funds received by or for each dependent. This would include, for example, wages, payments from social service agencies, Social Security, V.A. benefits and child support.
3. Show how you used each dependent’s income or other funds and the amounts contributed to the household expenses by each dependent living with you.
4. Send a copy of the birth certificate and social security card for each dependent claimed.
5. Send a copy of school, medical, or other records to determine each dependent’s place of residence.
6. Send a record of amounts contributed to household expenses by each person living in the household with the dependent.
7. If you were divorced or legally separated, send a complete copy of your divorce decree or separate maintenance agreement, including any modifications. Send a copy of any written agreement showing which parent will have custody and who can claim the dependent(s).
(Selective paragraph continues)
OTHER DEPENDENTS
(Selective paragraph continues)
1. Send a computation of the total cost of the dependent’s support as well as cancelled checks and receipts to verify amounts you spent for the dependent’s support. Provide a signed statement (Form 2120, Multiple Support Agreement) from each person with whom the dependent lived, confirming that they did not claim an exemption for the dependent(s). Statements should include their name, address and social security number.
2. Send a written statement showing the amount provided by any person or agency (such as, Social Security, social service agencies, Veterans Administration) that provided funds for the dependent’s support.
3. If you were divorced or separated, send a complete copy of your divorce decree, separate maintenance agreement, including any modifications, or any written statement stating which parent will have custody and claim the dependent(s).
4. Send a copy of Form 8332, Release of Claim to Exemption for Child of Divorced or Separated Parents, or similar written statement. This must be signed by the custodial parent agreeing not to claim an exemption for the child.
5. Send a copy of the birth certificate and social security card for all dependents.

G] FORMS W-2, 1098, 1099
Because your return did not report the same income or deductions as reported to IRS by employers or trustees, you must provide verification of all income received from the following sources:
1. Wages. Salaries, tips, fees, commissions (copies of Forms W-2).
2. Interest, dividends, unemployment compensation, proceeds from bartering, gambling winnings, prizes, awards, tips, disability income, etc (copies of Forms 1098,1099,5498, W-2G).
3. Pensions, annuities, royalties, estate or trust income and non-employee compensation (copy of Forms 1099R,1099S, 1099MISC, K-1).
4. Alimony received: (a copy of divorce decree or separation agreement).
5. Income earned from providing childcare.

H] INDIVIDUAL RETIREMENT ARRANGEMENTS
1. Send copies of the documents, which establish your Individual Retirement Arrangement (IRA) and copies of cancelled checks showing all contributions to the IRA for the year under examination.
2. Send copies of the documents showing sources of any rollover contributions to your IRA from a qualified pension or profit sharing plan or from another IRA, if applicable.

I] MOVING EXPENSES
1. Send copies of cancelled checks and receipts verifying the amount you paid to travel to your new home and to move your household goods and personal property.
2. Send a statement from your employer showing the allowance or reimbursement paid to you for moving expenses. This statement should identify the amounts by kind of expense, such as automobile, train, plane and transportation of household goods and personal property.
3. Send a statement from your employer as to whether the reimbursement was included on Form W-2.
4. Send the names and relationship of household members who moved with you.
5. Send the name and address of each employer you had since moving to your new place of employment and dates employed by each.
6. Send computations showing number of miles by direct route from your old residence to your new place of employment and from your old residence to your old place of employment.

J] SELF EMPLOYMENT HEALTH INSURANCE
1. Send proof of amount paid for health insurance.
2. If you or your spouse is an employee, send copies of statements from all your employers as to your eligibility to participate in the employer’s health plan at any time during the year.
3. Send proof the self-employment plan provides nondiscriminatory health insurance coverage to employees.

K] ALIMONY PAYMENTS
1. Send a copy of your divorce decree, separate maintenance agreement, or other instructions specifying the basis for alimony payments.
2. Send the current name, address, and social security number of the divorced or separated spouse.
3. Send copies of canceled checks or receipts to verify payments you made. If alimony payments were not made directly by you, provide copies of documents showing the source (such as an insurance policy, endowments, or annuity contract).

L] MEDICAL AND DENTAL EXPENSES
1. Send copies of cancelled checks, receipts or statements for all medical savings accounts, medical and dental expenses (including medical insurance) showing the person for whom each expense was incurred, along with any insurance or employer reimbursement records. Send a copy of your medical insurance handbook or policy describing the benefits and reimbursement policy and verification of premium cost.
2. For prescription drug expenses, send copies of statements or receipts showing the prescription numbers, names of drug, cost and date purchased.
3. For other expenses (including equipment, capital improvements, transportation and lodging) send proof of payment and statements to show cost and medical requirement.

M] STATE AND LOCAL INCOME TAXES/STATE TAX RETURN
1. Send copies of State, local, and Federal tax returns for the years involved.
2. Send copies of cancelled checks and receipts showing taxes paid.

N] REAL ESTATE AND PERSONAL PROPERTY TAXES
1. Send verification of your legal ownership of the property.
2. Send copies of cancelled checks, mortgage statements or receipts for taxes paid. Send a copy of your property tax bill and documentation for any property tax rebates or refunds.
3. Send a copy of the settlement statement if real property was sold or purchased during the year.
4. Send verification of any special assessments deducted as taxes and an explanation of their purpose.

O] INTEREST PAID
1. Send copies of mortgage interest statements, equity credit lines/loans, land and mortgage contracts, and amortization schedules for loans outstanding. Send copies of cancelled checks, receipts or other evidence of payments made for the year under examination.
2. Send copies of statements from financial institutions, investment brokerages or persons to verify your total investment interest deduction.

P] CONTRIBUTIONS
1. Send copies of your cancelled checks and receipts for contributions to churches or other organizations.
2. If the contribution was other than money, send the name and address of the charitable organization along with the description of the items contributed. Send a copy of the appraisal of the fair market value of each item on its contribution date and its original cost.
3. If you claimed expenses for attending a convention or similar activity, provide a statement showing you were an official representative of the organization. Also, provide the organization’s reimbursement policy, expense receipts and an itinerary or agenda for the activity.

Q] CASUALTY AND THEFT LOSS
1. If your property was insured, send a copy of the insurance report showing the date and nature of the loss or damage to the property. This report also should show the amount of damage, amount of coverage carried, and the date and amount of the claim paid by insurance, or the amount of the claim pending.
2. If your property was not insured, send copies of the fire or police department reports on losses from fire, theft, or accident.
3. Send photographs or videos showing the extent of the loss, if available.
4. Send an appraisal from a qualified estimator or adjuster showing the fair market value of the property before and after the casualty or showing an estimate of the damages.
5. Send verification of the cost or other basis of the property, the date it was acquired and the actual cost of repairs.

R] BUSINESS USE OF HOME-2106 EXPENSE
1. Send a statement from your employer stating that you are required to maintain an office in your home.
2. Send copies of cancelled checks and receipts verifying expenses incurred, such as interest, taxes, insurance, repairs and utilities.
3. Send a calculation of the total square footage of your home and the total square footage used for business.
4. Send copies of the documents that establish the cost or other basis of the home including the value of the land.

S] LEGAL, TAX, AND INVESTMENT COUNSEL FEES
1. Send copies of cancelled checks, receipts, and statements showing the amount of the payment and the purpose of the expense.

T] MISCELLANEOUS DEDUCTIONS
1. Verify the deductions claimed on your tax return and provide an explanation of each.

U] CREDIT FOR CHILD AND DEPENDENT CARE EXPENSES
1. If you were divorced or legally separated, send a complete copy of your divorce decree or separation agreement (including any modifications). Also send the dates you had custody of the child and dates the other parent had custody of the child.
2. Send the name, address and social security number of each person or organization you paid for childcare or for the care of a disabled dependent. Also send copies of cancelled checks and receipts documenting the expenditures. If you do not have cancelled checks, provide a statement from each person or organization showing his/its name, address, period of care and amount paid.
3. If the expenses were paid for a disabled dependent, send a doctor’s statement showing that the dependent was physically or mentally unable to care for himself or herself,
4. Send a statement from your employer outlining any dependent care benefits paid.

V] FOREIGN TAX CREDIT
1. Send copies of receipts or statements showing foreign source income and foreign income taxes paid or withheld from your earnings. Provide translations of the necessary words so that the following items are clear:

2. Send a complete copy of the tax return(s) filed with foreign authorities covering the same periods as your U.S. tax return. Clearly indicate the tax liability and refund (or balance due) on the foreign return.
3. Send a list and verification of the foreign taxes paid or accrued that relate to tax years other than the one being examined. Provide copies of foreign tax returns for those years.
4. Provide a schedule showing how you computed the credit carryback or carryover, if applicable.

W] FEDERAL INCOME TAX WITHHOLDING/EXCESS FICA
1. Send copies of all Forms W-2, W-2G, or 1099 to verify withholding or excess FICA withheld by employers or trustees.

X] CAR AND TRUCK
1. Send copies of repair receipts, inspection slips, and other records showing total mileage for the year.
2. Send copies of logbooks and other records to support business mileage claimed.
3. Provide a copy of your appointment book or calendar of business activities for the year.
4. If you are claiming actual expenses, please provide copies of paid bills, invoices and canceled checks or automobile expenses. These would include gas, oil tires, repairs, insurance, interest, tags, taxes, parking fees and tolls.
5. Send a copy of the bill of sale or other verification to establish your basis in the vehicle, including the trade-in of another vehicle.

Y] EDUCATION EXPENSES
1. Send a statement from your employer explaining whether you needed the education to keep your job, salary or status. Explain how the education helped maintain or improve the skills needed in your job and how much reimbursement you received. Break down the reimbursement by category of expense.
2. Send copies of cancelled checks and receipts to verify amounts you spent for tuition, books, transportation and other educational expenses. If you were away from home overnight for educational purposes, provide expense verification for your meals, lodging and travel.
3. Send documents such as transcripts, course descriptions and catalogs showing your period of enrollment in the educational institution and the principal subjects studied.
4. Provide complete information about any scholarship or fellowship grants, including amounts you received during the year.

Z] EMPLOYEE BUSINESS EXPENSES
1. Send a statement from your employer showing:

2. Send copies of the expense vouchers submitted to your employer.
3. Send copies of logs, diaries or other records of expenses showing all expenses incurred, job locations and dates you were at each location.

0] GAS, FUEL AND OIL
1. Send copies of cancelled checks and receipts for gas, fuel, and oil expense.
2. Send documentation that the amount of the Gas Tax Credit claimed was also reported as income

1] INSURANCE EXPENSE
1. Send copies of all insurance policies for which you deducted premiums.
2. Send copies of cancelled checks for insurance paid, or invoices for insurance owed.

2] JOB HUNTING
1. Send a copy of the log or diary showing your job-hunting activity and copies of canceled checks or receipts showing expenses paid, including payments to employment agencies.
2. Send a statement from your employer showing the amount of reimbursement, if any.
3. Send documents to establish type of job sought.

3] RENTAL
1. Send copies of cancelled checks and receipts to verify all rental expense claimed
2. Send a copy of the lease or rental agreement, canceled checks, and statements for rent paid or owed during the year

4] ENTERTAINMENT, MEALS, GIFTS AND OTHER EXPENSES
1. Send copies of the records and receipts for entertainment expenses and meals you claimed. The records must have been made timely and must show the name(s) and business relationship of the person(s) entertained. The records also must show the date, place and purpose of the entertainment and the amount of the expenditure.
2. For entertainment facilities, send copies of the records showing the expenses you incurred. Show total use, and business use of the facility if it was maintained by you.
3. For business gifts, send copies of records and receipts showing the cost of the gifts you provided, the persons to whom the gifts were given and their business relationship.

5] TRAVEL, LODGING, AND OTHER EXPENSES
1. Send copies of documents showing that this travel was related to your business.
2. Send copies of transportation tickets, receipts and cancelled checks to substantiate the expenses you claimed.
3. Send copies of lodging receipts and verification of the number of days away from home overnight for business purposes.
4. Send copies of brochures, activity schedules and agendas for all conventions, cruises or meetings.

6] UNIFORMS, EQUIPMENT AND TOOLS
1. Describe the items claimed and explain how they related to your employment.
2. Send a statement from your employer stating whether or not the expense was required, Also provide your employer’s description of the reimbursement policy and the amount reimbursed or allowance paid.
3. Send copies of canceled checks and receipts verifying expenses.

7] BAD DEBTS/BAD DEBTS FROM SALES OR SERVICES
1. Send a verification of your debt, such as a note or contract establishing the debtor-creditor relationship.
2. Send the full name and the last known address of the debtor.
3. Send evidence of your efforts to collect the debt.
4. Send evidence of the uncollectability of the debt in the year claimed.
5. Send evidence that the debt previously was included in income.

8] COPIES OF ALL FORMS 1099 FOR COMMISSIONS PAID.
1. If Forms 1099 were not issued, send the names, addresses, and social security numbers for recipients of commissions who are individuals.
2. Send copies of contracts or other written agreements for contract labor.
3. Send copies of cancelled checks and all other records to verify amounts paid to each individual and in each contract.

9] COST OF GOODS SOLD
1. Send copies of the physical inventory sheets for both the beginning and the ending inventory for the year.
2. Send copies of receipts, cancelled checks, purchase journals or summaries and all other records for materials, supplies and other costs incurred to raise, produce or purchase goods for resale.
3. Send copies of cancelled checks, contracts and other records to verify the amount paid to each individual or contractor. Send the names, addresses and social security numbers of individuals paid.
4. Send the description and computation of the cost of the inventory items withdrawn for personal use. Include gifts to family and friends and items for personal consumption.

a] COST OF LIVESTOCK OR OTHER ITEMS BOUGHT FOR RESALE
1. Send copies of the physical inventory sheets for both the beginning and the ending inventory for the year.
2. Send copies of the receipts, cancelled checks and purchase journals or summaries for goods purchased for resale.
3. Send the description and computation of the cost of inventory items withdrawn for personal use. Include gifts to family and friends and items for personal consumption.

b] DEPRECIATION/SECTION 179
1. Send copies of the purchase invoices, settlement sheets, receipts and any other evidence to verify ownership of the assets.
2. Send a computation of how you determined that the depreciable basis of the assets. Provide a detailed depreciation schedule for all assets.
3. Send copies of records and log books showing the total business and personal use of the depreciable assets.
4. For real property, verify your ownership of the property, the date acquired, the cost of the property, the land allocation and the cost of improvements or additions to the property.

c] DEPRECIATION OF RENTAL PROPERTY
1. Send evidence to verify your ownership of the property, the date acquired, the cost and the computation of basis if different from cost. Also, send a calculation showing allocation of basis to land and to buildings and another to show the cost of improvements and additions to the property.
2. Send a schedule of depreciation computed for the current and prior year.

d] GROSS RECEIPTS
1. Send a brief history of your business operations.
2. Send copies of all books, journals, ledgers and workpapers used to determine gross receipts.
3. Send copies of all bank statements and deposit slips, both business and personal, savings and checking, for the 14 month period from December through January of the year in question.
4. Send records of all savings and invested funds, for the year. This would include such investment vehicles as money market accounts, certificates of deposit and other items.
5. Send copies of records and documentation of all other business and personal receipts. These might be loans, insurance proceeds, inheritances, salaries, employer reimbursements, gifts, Social Security benefits and transfers between bank accounts.
6. Send copies of purchase invoices or closing statements for acquisitions and dispositions of business and personal capital items. This includes real estate, automobiles, machinery and equipment, etc.

e] MACHINE AND LABOR HIRE
1. Send copies of all Forms 1099 for machine expenses paid.
2. If Forms 1099 were not issued to individuals who were paid for machine work, provide the names, addresses, and social security numbers of those individuals.
3. Send copies of cancelled checks, invoices and other records to verify amount paid.

f] OFFICE IN THE HOME-SCHEDULE C EXPENSE
1. Send copies of statements from third parties, if applicable, showing you were required to provide an office in your home or elsewhere.
2. Send copies of canceled checks or receipts verifying expenses incurred such as interest, taxes, insurance, and utilities.
3. Send copies of records to support cost basis for depreciation.
4. Send verification of the square footage of the home and the total square footage in the area used for business.

g] PENSION OR PROFIT SHARING PLANS
Please provide copies of cancelled checks and other documents verifying the establishment of and contributions to the plan for the year.

h] RENT EXPENSE
Send copies of the lease or rental agreement, canceled checks, and statements for the rent paid or owed during the year.

i] RENTAL INCOME
1. Send evidence to verify your ownership of the property.
2. Send copies of receipts, lease agreements and other records showing the total amount of rent you received.
3. Send a statement from a real estate agent showing the fair rental value for similar properties in the same geographic area. If any of the units were occupied rent-free or below fair rental value during the year, provide an explanation.
4. Tell us the total number of days the unit was rented and the number of days the unit was used for personal purposes.
5. If the property was converted from a personal residence to rental property give the date of the conversion.

j] SALARIES AND WAGES PAID
1. Send copies of the employment tax returns (Forms 940, 941, or 943) to support your deduction for salaries and wages paid to employees.
2. Send copies of Forms W-2, W-4, and 1099 for all employees.
3. Send copies of payment records, including canceled checks, for salaries and wages paid.

k] SCHEDULE D - SALES OF REAL AND PERSONAL PROPERTY
1. Send a copy of the bill of sale or closing/settlement statement for the purchase of the property.
2. Send copies of the verification of the capital improvements made to the property, such as receipts, bills and/or contracts.
3. Send a copy of the closing statement and the records showing the terms and expenses of the sale.
4. If the property was repossessed or foreclosed, send a copy of the income tax return for the year of the original sale. Also send copies of all contracts or legal documents involved, and verification of the repossession or foreclosure costs.
5. Send copies of documents to verify the purchase cost and sales price of other capital assets sold.

l] STOCK SALES
1. Send copies of brokerage vouchers and monthly statements establishing the purchase price, the sales price and the dates of transactions.
2. If you sold securities on which you had a return of capital or stock splits, send copies of your records showing distributions received during the holding period, For worthless securities, provide verification of the dissolution or liquidation and the amount of the liquidating distribution.

m] STUDENT LOAN INTEREST
1. Send copies of student loan contracts (original and refinanced), interest paid statements and cancelled checks or receipts to verify payments.
2. Send copies of transcripts for all years that you incurred student loans.
3. Send copies of receipts for all education costs, such as tuition, fees, room and board, books and equipment.
4. Send statements for all nontaxable sources of income from:

5. Send copies of all tax returns for years that you incurred student loans.

n] MEDICAL SAVINGS ACCOUNT
1. Send copies of statements from all employers showing the total number of employees and total contributions made to your medical savings account (if a joint return, both spouses).
2. Send a copy of all health insurance plans.
3. Send copies of cancelled checks or other verification of contributions.

o] SALE OF PERSONAL RESIDENCE
1. Send copies of closing statements for the sale of the residence and for the cost of the residence when it was purchased.
2. Send copies of cancelled checks and receipts for improvements made to the residence that was sold.
3. Send a copy of documentation for any casualty loss deduction previously claimed.
4. Send a copy of documentation for any other sales of personal residence(s) within the previous 2 years.
5. If the residence was converted to rental or business use, give the date of the conversion and the date it reverted to personal use.
6. Send a copy of your income tax return for the last year the home was used for business before the sale.
7. Provide copies of all Forms 2119 from prior years to verify the adjusted basis of the residence sold.