Form 4180 - Report Of Interview With Individual Relative To Trust Fund Recovery Penalty Or Personal Liability For Excise Taxes

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Interview Handouts
Instructions
Report of Interview with
(''X'' if given or explain why not in case history.)
The interviewer
prepare
must
Individual Relative to Trust
Privacy Act Notice
Notice 609,
this form either in person or via
Fund Recovery Penalty or
telephone.
leave any
Do not
Could You be Personally
Notice 784,
information blank. Enter ''N/A''
Liable for Certain Unpaid Federal
Personal Liability for Excise Taxes
if an item is not applicable.
Taxes?
IRC 6672, Failure to collect and pay over tax from
to
(mmddyyyy)
Type of Interview
("x" one.)
IRC 4103, Failure to pay excise taxes from
to
(mmddyyyy)
Section I.
Background Information for Person Interviewed
1. Name
2. Social Security Number
(SSN)
4. Home telephone number
3. Address
(Street, City, State, ZIP code)
(
)
5. Work telephone number
(
)
6. What was your job title and how were you associated with the business?
(Describe your duties and responsibilities and dates of employment.)
7. Did you resign from your position?
8. Did you have your name removed from
the bank signature cards?
No
Yes
N/A
a. When?
No
Yes
No
b. Is a copy available?
Yes
c. To whom was it submitted?
When?
9. Do you have any money invested
10. Have you ever been involved in another business that had tax problems?
in the business?
No
No
Yes
(Provide explanation; i.e., Name of business, ID number, amount, etc.)
Yes
What amount do you have invested?
$
Background Information for Business Entity
Section II.
(Complete shaded items only if this is the first Form 4180 secured on the business entity.)
1. Name of Business
2. Business telephone number
(
)
3. Address
4. Has the business ever filed bankruptcy?
(Street City State, ZIP code)
No
Date filed:
Yes
Chapter:
Petition #
5. Type of Entity
Sole Proprietor
Partnership
Limited Liability Company
(LLC)
Corporation
How is the LLC treated for tax purposes?
Date incorporated
Disregarded Entity
State where incorporated
Taxed as a Partnership
Has the state ever revoked the charter?
Taxed as a Corporation
No
Yes
When?
4180
Page 1 of 5
Department of the Treasury – Internal Revenue Service
Form
(Rev. 9-2004)
Catalog No. 22710P

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