Employer Tax Form Packet (Page 5 of 9) in pdf

8821

OMB No. 1545-1165

Tax Information Authorization

For IRS Use Only

Form

Received by:

Information about Form 8821 and its instructions is at

Name

▶

(Rev. October 2012)

Telephone

Do not sign this form unless all applicable lines have been completed.

▶

Department of the Treasury

Function

To request a copy or transcript of your tax return, use Form 4506, 4506-T, or 4506T-EZ.

▶

Internal Revenue Service

Date

1 Taxpayer information. Taxpayer must sign and date this form on line 7.

Taxpayer identification number(s)

Taxpayer name and address (type or print)

Daytime telephone number

Plan number (if applicable)

2 Appointee. If you wish to name more than one appointee, attach a list to this form.

CAF No.

Name and address

PTIN

See Attached List

Telephone No.

Fax No.

Check if new: Address

Telephone No.

Fax No.

3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information for the tax matters listed on this

line. Do not use Form 8821 to request copies of tax returns.

(a)

(b)

(c)

(d)

Type of Tax

Tax Form Number

Year(s) or Period(s)

Specific Tax Matters (see instr.)

(Income, Employment, Payroll, Excise, Estate,

(1040, 941, 720, etc.)

(see the instructions for line 3)

Gift, Civil Penalty, etc.) (see instructions)

Employment

940,941,941X,W2,W2(c),

Quarters 1-4 in 2013-2016

Employment

W-3,W-3(c),1096,1099

Quarters 1-4 in 2013-2016

Other

SS-4,2678,2848,8821,8822b

Quarters 1-4 in 2013-2016

4 Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific

use not recorded on CAF, check this box. See the instructions. If you check this box, skip lines 5 and 6 .

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5 Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):

a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing

basis, check this box

▶

Note. Appointees will no longer receive forms, publications and other related materials with the notices.

b If you do not want any copies of notices or communications sent to your appointee, check this box

▶

6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior

authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want

to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect

and check this box .

▶

To revoke this tax information authorization, see the instructions.

7 Signature of taxpayer. If signed by a corporate officer, partner, guardian, executor, receiver, administrator, trustee, or

party other than the taxpayer, I certify that I have the authority to execute this form with respect to the tax matters and tax

periods shown on line 3 above.

IF NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.

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DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

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Signature

Date

Household Employer

Print Name

Title (if applicable)

PIN number for electronic signature

8821

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

Form

(Rev. 10-2012)

Cat. No. 11596P

Employer Tax Form Packet Page 5

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