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9041

Form

Application for Electronic/Magnetic Media Filing of

(Rev. September 1999)

OBM No. 1545-1079

Department of the Treasury

Business and Employee Benefit Plan Returns

Internal Revenue Service

This application is: (check one)

new

revised

See the back of this form for line by line instructions

1a Firm's Name

b Employer Identification Number (EIN)

(EIN must be 9 digits)

c Mailing Address (Street, P.O. Box, City, State, Zip Code)

d Contact person's name

Daytime telephone number

(Include area code.)

( ___ ) ____________________

FAX telephone number

(Include area code.)

( ___ ) ____________________

Indicate which forms you will file by checking each appropriate box.

Form 1041, U.S. Income Tax Return for Estates

Form 5500, Annual Return/Report of Employee Benefit Plan

and Trusts

(with 100 or more Participants)

Form 1065, U.S. Partnership Return of Income

Form 5500-C/R, Return/Report of Employee Benefit Plan

)

(See back of this form for instructions

(with fewer than 100 Participants)

Form

Form 5500-EZ, Annual Return of One-Participant

(Owners and Their Spouses) Retirement Plan

Form

List any Electronic Transmitter Identification Number(s) and Magnetic Media Transmitter Identification Number(s) we

previously assigned to you or your firm.

Please answer the following questions by checking the appropriate box(es):

a Will you send return data directly to IRS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

b Will you develop or modify software that prepares returns for electronic/magnetic media filing? . . .

Yes

c Will you file using Magnetic tape?

Floppy Diskette (3 1/2" or 5 1/4")?

Modem?

If you know which software company and/or transmission service you will use, please enter the names, addresses and

phone numbers below.

Software Company

Transmitter

Estimated tax return volume to be filed:

K-1 . . . . . . .

Form . . . . . . .

Under the penalties of perjury, I declare that I have examined this application and any accompanying information,

and to the best of my knowledge and belief it is true, correct and complete. This firm and its employees will comply

with all the provisions of the procedures for electronic/magnetic media filing of Forms 1041, 1065, 5500, 5500-C/R,

Applicant

or 5500-EZ as applicable. The firm understands that if it is sold or its organizational structure is changed, acceptance

Agreement

for participation is not transferable; a new application must be filed. The firm further understands that noncompliance

will result in the firm no longer being allowed to participate in the program. I am authorized to make and sign this

statement on behalf of the firm.

Name and title of person responsible for filing this application (Please print or type.)

Signature of person responsible for this application

Date

For Privacy Act and Paperwork Reduction Act Notice, See back of this form

9041

Cat. No. 10333U

Form

(Rev. 9-1999)

Form 9041 - Application For Electronic/magnetic Media Filing Of Business And Employee Benefit Plan Returns

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