2005 Form 8453-Ol - U.s. Individual Income Tax Declaration For An Irs E-File Online Return
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2Declaration Control Number (DCN)
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IRS Use Only—Do not write or staple in this space.
U.S. Individual Income Tax Declaration
OMB No. 1545-0074
8453-OL
for an IRS e-file Online Return
2005
For the year January 1–December 31, 2005
Department of the Treasury
See instructions on back.
Internal Revenue Service
Your first name and initial
Last name
Your social security number
L
A
Use the
B
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
IRS label.
E
Otherwise,
L
please
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Important!
H
print or
You must enter
E
type.
your SSN(s) above.
R
City, town or post office, state, and ZIP code
Daytime phone number
E
(
)
Part I
Tax Return Information (Whole dollars only)
1
1
Adjusted gross income (Form 1040, line 38; Form 1040A, line 22; Form 1040EZ, line 4)
2
2 Total tax (Form 1040, line 63; Form 1040A, line 38; Form 1040EZ, line 10)
3
3
Federal income tax withheld (Form 1040, line 64; Form 1040A, line 39; Form 1040EZ, line 7)
4
4
Refund (Form 1040, line 73a; Form 1040A, line 45a; Form 1040EZ, line 11a)
5
Amount you owe (Form 1040, line 75; Form 1040A, line 47; Form 1040EZ, line 12) (see instructions)
5
Part II
Declaration of Taxpayer. Be sure to keep a copy of your tax return.
I consent that my refund be directly deposited as designated in the electronic portion of my 2005 Federal income
6a
tax return. If I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to receive
the refund.
I do not want direct deposit of my refund or I am not receiving a refund.
b
c
I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal entry
to the financial institution account indicated in the tax preparation software for payment of my Federal taxes owed
on this return and/or a payment of estimated tax. I further understand that this authorization may apply to future
Federal tax payments that I direct to be debited through the Electronic Federal Tax Payment System (EFTPS). In
order for me to initiate future payments, I request that the IRS send me a personal identification number (PIN) to
access EFTPS. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent
to terminate the authorization. To revoke a payment, I must contact the U.S. Treasury Financial Agent at
1-888-353-4537 no later than 2 business days prior to the payment (settlement) date. I also authorize the financial
institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary
to answer inquiries and resolve issues related to the payment.
If I have filed a balance due return, I understand that if the IRS does not receive full and timely payment of my tax liability,
I will remain liable for the tax liability and all applicable interest and penalties. If I have filed a joint Federal and state tax
return and there is an error on my state return, I understand my Federal return will be rejected.
Under penalties of perjury, I declare that I have examined a copy of my electronic individual income tax return and
accompanying schedules and statements for the tax year ending December 31, 2005, and to the best of my knowledge and
belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts shown on the
copy of my electronic income tax return. I consent to allow my intermediate service provider and/or transmitter to send my
return to the IRS and to receive from the IRS (a) an acknowledgment of receipt or reason for rejection of the transmission,
(b) an indication of any refund offset, (c) the reason for any delay in processing the return or refund, and (d) the date of any
refund.
Sign
Here
Your signature
Date
Spouse’s signature. If a joint return, both must sign.
Date
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 15907C
8453-OL
Form
(2005)
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