Form 2750 - Waiver Extending Statutory Period For Assessment Of Trust Fund Recovery Penalty
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3Department of the Treasury–Internal Revenue Service
2750
Waiver Extending Statutory Period for Assessment of Trust Fund Recovery Penalty
Form
(Rev. 5-2003)
(Section 6672, Internal Revenue Code, or corresponding provisions of prior internal revenue laws)
1. Name and address of person potentially responsible
2. Social security number (SSN)
The person named above and the Area Director of Internal Revenue or the Director of Appeals agree that the
3. Statutory period extended to
penalty under Internal Revenue Code section 6672 (applicable to the tax for the periods shown below) may
be assessed against that person on or before the date shown at the right. This agreement extends the
statutory period for assessing the penalty. It does not mean that the person named accepts responsibility
for the penalty.
4.
Taxpayer Data
Name and Address of Employer or Collection Agency
Form Number
Tax Period Ended
Employer Identification
Number (EIN)
I understand that I have a right to refuse to sign this waiver or to limit the extension to particular issues or
Person
periods of time as set forth in I.R.C. § 6501(c)(4)(B).
Potentially
5. Signature
6. Date
Responsible
7. Name of Area Director
8. Name of Director of Appeals
or
10. Date
9. By
(Signature and title)
2750
Part 1— IRS Copy
Catalog Number 18857L
Form
(Rev. 5-2003)
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