Reporting Agent Authorization Form (Page 2 of 3) in pdf

OMB No. 1545-1058

Reporting Agent Authorization

(In accordance with IRS Form 8655)

Taxpayer

Employer identiﬁcation number (EIN)

Other identiﬁcation number (State ID)

If you are a seasonal employer,

check here .................................

Name of taxpayer (as distinguished from trade name)

Trade name, if any (DBA)

Address (number, street, and room or suite no.)

City or town

State

ZIP code

Contact person

Telephone number

Fax number

Reporting Agent

10.

Name

A D V A N T A G E

P A Y R O L L

S E R V I

C E S

I N C

11.

Address

12. Employer identiﬁcation number (EIN) 13. Telephone number

1 7

J O H N

S T

0 1

0 2

8 7 1 4

8 6 6

7 1 7

9 7 7 8

City or town

State

ZIP code

W E S T

H E N R I

E T T A

N Y

4 5 8 6

9 1 9

Authorization of Reporting Agent To Sign and File Returns

(Caution: See Authorization Agreement)

14.

Use the entry lines below to indicate the tax return(s) to be ﬁled by the reporting agent. Enter the beginning year of annual tax returns or beginning

quarter of quarterly tax returns. See the instructions for how to enter the quarter and year. Once this authority is granted, it is effective until revoked by

the taxpayer or reporting agent.

Y Y Y Y

M M

Y Y Y Y

940

941

943

944

945

Authorization of Reporting Agent To Make Deposits and Payments

(Caution: See Authorization Agreement)

15.

Use the entry lines below to enter the starting date (the ﬁrst month and year) of any tax return(s) for which the reporting agent is authorized to

make deposits or payments. See the instructions for how to enter the month and year. Once this authority is granted, it is effective until revoked by

the taxpayer or reporting agent.

M M

Y Y Y Y

M M

Y Y Y Y

M M

Y Y Y Y

M M

Y Y Y Y

941

940

943

944

945

Disclosure of Information to Reporting Agents

16a.

Check here to authorize the reporting agent to receive or request copies of tax information and other communications from the IRS related to the

authorization granted on line 14 and/or line 15 ...............................................................................................................................................................

................................................................. X

Check here if the reporting agent also wants to receive copies of notices from the IRS

Form W-2 series or Form 1099 series Disclosure Authorization

17a.

The reporting agent is authorized to receive otherwise conﬁdential taxpayer information from the IRS to assist in responding to certain IRS notices

relating to the Form W-2 series information returns. This authority is effective for calendar year forms beginning

Y Y Y Y

The reporting agent is authorized to receive otherwise conﬁdential taxpayer information from the IRS to assist in responding to certain IRS notices

relating to the Form 1099 series information returns. This authority is effective for calendar year forms beginning

Y Y Y Y

State or Local Authorization

(Caution: See Authorization Agreement)

18.

Check here to authorize the reporting agent to sign and ﬁle state or local returns related to the authorization granted on line 14 and/or line 15 .........

Authorization Agreement

I understand that this agreement does not relieve me, as the taxpayer, of the responsibility to ensure that all tax returns are ﬁled and that all

deposits and payments are made and that I may enroll in the Electronic Federal Tax Payment System (EFTPS) to view deposits and payments

made on my behalf. If line 14 is completed, the reporting agent named above is authorized to sign and ﬁle the return indicated, beginning with the quarter

or year indicated. If any starting dates on line 15 are completed, the reporting agent named above is authorized to make deposits and payments beginning

with the period indicated. Any authorization granted remains in effect until it is revoked by the taxpayer or reporting agent. I am authorizing the IRS to disclose

otherwise conﬁdential tax information to the reporting agent relating to the authority granted on line 14 and/or line 15, including disclosures required to process

Form 8655. Disclosure authority is effective upon signature of taxpayer and IRS receipt of Form 8655. The authority granted on Form 8655 will not revoke any

Power of Attorney (Form 2848) or Tax Information Authorization (Form 8821) in effect.

I certify I have the authority to execute this form and authorize disclosure of otherwise conﬁdential information on behalf of the taxpayer.

Signature

Title

Date

REQUIRED

For Privacy Act and Paperwork Reduction Act Notice, see reverse.

Ofﬁce/Client number

Rev. 8/14

WFA