Form 3465, Adjustment Request, for Assessment of PenaltySummary: This is an example of a Form 3465, Adjustment Request, showing the following blocks filled in to request assessment of penalty other than delinquency or failure to pay (i.e., IRC Section 6660 penalty):Original DLNTaxpayer's name or name controlEmployer's Identification Number (EIN) or SSNMFT CodePeriod Ending (Year, month)Form numberRemarks (6660 penalty, $3,169.00, apply to assessments)Signature of requestorUnitPhone extensionDate