﻿Department of the Treasury -Internal Revenue Service

Form 15105
(June 2017)
No Breakdown of Liability By Abstract Number on Form 720

Complete this form and send it to us in the enclosed envelope.

Contact information

Employer Identification Number ----
Business name ----
Tax period(s) ----

If your address has changed, provide the current address below, call 1-866-699-4096 or visit www.irs.gov

Address ----
City ----
State ----
ZIP code ----
Primary telephone number ----
Best time to call ----
-- a.m.
-- p.m.
Secondary telephone number ----
Best time to call ----
-- a.m.
-- p.m.

Tax Breakdown

Type of tax ----
Amount ----
IRS number ----
Type of tax ----
Amount ----
IRS number ----
Type of tax ----
Amount ----
IRS number ----

Mail your response to us within 30 days from the date of the attached notice. If you're using your own envelope, mail your package to the address shown on the notice.

Catalog Number 69799G
www.irs.gov
Form 15105 (6-2017)
