Form 870-E - Waiver Of Restrictions On Assessment And Collection Of Deficiency And Acceptance Of Overassessment

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Date received by Internal
Department of the Treasury-Internal Revenue Service
870-E
Form
Revenue Service
Waiver of Restrictions on Assessment and Collection of
(Rev. 1-2004)
Deficiency and Acceptance of Overassessment
Name of Taxpayer, Address (Number, street, city or town) State, ZIP Code
Social Security or Employer Identification Number
Name of Private Foundation or Other Exempt Organization
In
regards to:
Increase (Decrease) in Tax and Penalties
Taxable Year
Internal Revenue Code Section
Penalty
Amount of Tax
Ended
Consent to Assessment and Collection
I consent to the immediate assessment and collection of any deficiencies (increase in tax and penalties) against (1) the
exempt organization named above, or (2) me, as a manager of a private foundation or other exempt organization named
above, or (3) me, as a disqualified person with respect to the exempt organization named above, and accept any
overassessment (decrease in tax and penalties) shown above, plus any interest provided by law. I understand that by signing
this waiver, I will not be able to contest these years in the United States Tax Court, unless additional deficiencies are
determined for these years.
Date
Disqualified Person's, Foundation or Organization Manager's Signature
Date
Taxpayer's Representative's Signature
Corporate/Trust/Partnership Organization Name
Title
Date
Signature
Authorized
Official
Signature
Title
Date
Authorized
Official
870-E
Form
(Rev. 1-2004)
Catalog Number 16898M
Department of the Treasury-Internal Revenue Service

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