Form 8879 - Irs E-File Signature Authorization

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8879
OMB No. 1545-1758
Form
IRS e-file Signature Authorization
2001
Department of the Treasury
Internal Revenue Service
Declaration Control Number (DCN)
Taxpayer’s name
Social security number
Spouse’s name
Spouse’s social security number
Part I
Tax Return Information—Tax Year Ending December 31, 2001 (Whole Dollars Only)
1
1
Adjusted gross income (Form 1040, line 33; 1040A, line 19; 1040EZ, line 4)
2
2
Total tax (Form 1040, line 58; 1040A, line 36; 1040EZ, line 11)
3
3
Federal income tax withheld (Form 1040, line 59; 1040A, line 37; 1040EZ, line 8)
4
4
Refund (Form 1040, line 68a; 1040A, line 43a; 1040EZ, line 12a)
5
Amount you owe (Form 1040, line 70; 1040A, line 45; 1040EZ, line 13)
5
Part II
Declaration and Signature Authorization of Taxpayer
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, 2001, 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 acknowledge that I have read the Consent to Disclosure and, if applicable, Electronic Funds Withdrawal Consent
included on the copy of my electronic income tax return and I agree to the provisions contained therein. I have selected a personal
identification number (PIN) as my signature for my electronic income tax return and, if applicable, my Electronic Funds Withdrawal
Consent.
Taxpayer’s PIN: check one box only
I authorize
to enter my PIN
as my signature
on my tax year 2001 electronically filed income tax return.
I will enter my PIN as my signature on my tax year 2001 electronically filed income tax return.
Your signature
Date
Spouse’s PIN: check one box only
I authorize
to enter my PIN
as my signature
on my tax year 2001 electronically filed income tax return.
I will enter my PIN as my signature on my tax year 2001 electronically filed income tax return.
Spouse’s signature
Date
Practitioner PIN Program Participants Only—continue below
Part III
Certification and Authentication—Practitioner PIN Program Participants
ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN.
As a participant in the Practitioner PIN Program, I certify that the above numeric entry is my PIN, which is my signature on
the tax year 2001 electronically filed income tax return for the taxpayer(s) indicated above. I confirm that I am participating
in the Practitioner PIN Program in accordance with the requirements established for this program.
ERO’s signature
Date
ERO Must Retain This Document — See Instructions
Do Not Submit This Document To the IRS Unless Requested To Do So
See Privacy Act and Paperwork Reduction Act Notice
8879
For Privacy Act and Paperwork Reduction Act Notice, see back of form.
Cat. No. 32778X
Form
(2001)

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