Form 15109

(Rev. January 2023)

Request For Tax Deferment

OMB Number 1545-2286

Catalog Number 69803D

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Important Things You Should Know

To be considered for tax deferment, please complete this form, and send it to us using the Document Upload Tool along with the required supporting documents. Refer to your notice CP04 for information on the Document Upload Tool. You can also send this form to us in the enclosed envelope or, you can fax it to us at 855-233-8562.

Make sure to include dates of entry and exit from your service in any combat zones, contingency operations, or hazardous duty stations that began or ended during the periods on the attached notice. For qualifying areas, refer to Publication 3, Armed Forces Tax Guide, under the heading Combat Zone Defined.

All fields marked with an asterisk (*) are required.

Combat Zone Information

Your name

SSN

Please enter a valid SSN without dashes.

Tax form and year

Tax Form

Tax Year

Name of organization, employer or military department

Telephone number of organization, employer or military department

Enter all numbers no dashes or parenthesis. ex '9999999999'.

Name of combat zone or other area

Date of entry