Addressee and date
The To: line for the IRS Independent Office of Appeals Team Manager, and the date.
13369
Agreement to Mediate
- Agency
- IRS
- Revision
- March 2022
- Fillable fields
- 41
- Pages
- 2
- Official source
- IRS form page
- Checked
- October 21, 2026
Form 13369: Agreement to Mediate
Form 13369, Agreement to Mediate, is addressed to an IRS Independent Office of Appeals Team Manager. It records a case to be mediated: the compliance officer handling it, the taxpayer and any representative, the tax years, and the type of tax or collection issue, with the form's own examples 1040, 1120, Emp., CDP and OIC.
The form's privacy notice says its primary purpose is to obtain acknowledgement that the taxpayer agrees to adhere to the mediation rules, agrees to the disclosures authorized by the signature on the form, and consents to all conditions authorized by the form. The taxpayer, the representative and the compliance officer each sign it.
The IRS publishes no separate instructions for this form; everything here comes from the form itself. You can fill out Form 13369 free in your browser on this page and download the result without an account.
What's on Form 13369
Compliance officer information
Name, title, office telephone number and ID/badge number of the person to contact in Compliance.
Case details
Taxpayer's identification number (TIN), year(s), source (FE/OE/CO, etc.), MFT, and the type of tax or collection issue.
Taxpayer and representative
Taxpayer's name, phone and home street address, then the representative's name, firm, office street address, phone and fax.
Terms and consent
Confidentiality and disclosure statements, the mediator's right to ask for more information, and the taxpayer's consent to disclosure of return information.
Signatures and participants
Signature and date lines for two taxpayers, the representative and the compliance officer, and the Other Participants (If Applicable) table.
How to fill out Form 13369
- 1
Date
Enter the date beside the To: line addressed to the IRS Independent Office of Appeals Team Manager.
- 2
Compliance officer
Enter the compliance officer's name, title, office telephone number with area code and ID/badge number.
- 3
Case details
Enter the TIN, the year(s), the source, the MFT and the type of tax or collection issue. The form gives examples: 1040, 1120, Emp., CDP and OIC.
- 4
Taxpayer and representative
Enter names, phone numbers and street addresses. The form says p.o. boxes are not allowed for the taxpayer's home address or the representative's office address.
- 5
Signatures
The taxpayer(s), the representative and the compliance officer each sign and enter the date signed after the terms and consent paragraphs.
- 6
Other participants
If others take part, list each one's name, position or affiliation and telephone number with area code.
Why fill Form 13369 on indox
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Where it goes, confidentiality and consent
Where it goes
The form is addressed to the IRS Independent Office of Appeals Team Manager. It prints no mailing address or deadline, and says not to send the completed form to the Tax Forms Committee.
Power of attorney
The form says a power of attorney used to sign it must clearly grant authority to consent to disclosure to third parties, and a copy must be attached to the agreement.
Sharing submissions
The form says a copy of any submission a party gives to the mediator will be provided simultaneously to the other party, and the mediator may ask either party for more information.
Confidentiality
IRS and Treasury participants are subject to I.R.C. sections 6103, 7213, 7213A and 7431, and the form also cites 5 U.S.C. section 574 and section 7214(a)(8).
Voluntary information
The privacy notice says providing the information is voluntary, but not providing all or part of it may preclude or impede participation in the mediation process.
Time to complete
The privacy notice gives an estimated average time of 3 minutes.
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Who completes Form 13369?
The form is a joint agreement. It is addressed to an Appeals Team Manager and has signature lines for the taxpayer, the taxpayer's representative and the IRS compliance officer, plus space for other participants.
Official sources and the blank
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Questions about Form 13369
Who is Form 13369 addressed to?
The IRS Independent Office of Appeals Team Manager.
Who signs Form 13369?
The form has signature lines for two taxpayers, the taxpayer's representative and the IRS compliance officer.
What does the taxpayer consent to?
The form says the taxpayer consents to the disclosure by the IRS of returns and return information incident to the mediation to participants or observers, including persons providing expert assistance for the IRS.
Can a representative sign under a power of attorney?
The form says the power of attorney has to clearly grant authority to consent to disclosure to third parties, and a copy has to be attached to the agreement.
Does the other side see what is given to the mediator?
The form says a copy of any submission a party gives to the mediator will be provided simultaneously to the other party.
Are there instructions for Form 13369?
The IRS publishes no separate instructions. The form itself carries the terms, the consent paragraph and a privacy notice.