Form 911AL, Request for Taxpayer Assistance Completed Form Examples and Samples
Explore detailed examples and samples of a completed IRS Form 911AL, Request for Taxpayer Assistance. Learn how to fill out the form to prevent levies, stop collection actions, and resolve significant hardships by requesting help from the Taxpayer Advocate Service (TAS).
Form 911AL Example – Requesting Assistance to Prevent a Bank Levy
How this form was filled:
This example demonstrates how to complete Form 911AL when facing a significant hardship, such as an impending IRS bank levy that would prevent you from meeting basic living expenses. The form clearly outlines the taxpayer's problem, the unsuccessful attempts to resolve it with the IRS, and the specific assistance requested from the Taxpayer Advocate Service (TAS).
Information used to fill out the document:
- Taxpayer Name: Jane Smith
- Social Security Number (SSN): 987-65-4321
- Address: 456 Oak Avenue, Anytown, AL 35203
- Phone Number: (205) 555-1234
- Tax Year in Question: 2024
- Tax Form Filed: Form 1040
- IRS Action: Final Notice of Intent to Levy
- Problem Summary: Received a notice of levy for a $5,000 tax debt. A levy would leave me unable to pay rent and buy groceries.
- Hardship Explanation: The taxpayer is a single parent and the funds in the bank account are required for immediate living expenses, including rent due at the end of the month and food. A levy would result in eviction and inability to provide for their child.
- Requested Resolution: Place a hold on the levy action and establish an affordable installment agreement.
- Signature: Jane Smith
- Date: 01/15/2026
What this filled form sample shows:
- Clearly identifies the taxpayer information and the specific tax year.
- Provides a compelling description of the **significant hardship** the IRS action would cause.
- Documents that the taxpayer has tried to resolve the issue with the IRS but has been unsuccessful.
- Specifies a clear and reasonable desired outcome for the Taxpayer Advocate to pursue.
Form specifications and details:
| Form: | Form 911AL |
| Use Case: | Preventing an IRS bank levy due to significant economic hardship. |
| Jurisdiction: | Alabama (local version of Form 911) |
| Categories: | taxpayer assistance forms |
| Created: | February 25, 2026 07:07 PM |