Fillable Form 8453-Ex - Excise Tax Declaration For An Irs E-File Return printable pdf download

8453-EX

Excise Tax Declaration for an IRS e-file Return

Form

For the period beginning

, 20

, and ending

, 20

OMB No. 1545-2082

(Rev. December 2011)

For use with Forms 720, 2290, and 8849.

Department of the Treasury

File electronically. Do not file paper copies.

See instructions.

▶

Internal Revenue Service

Name (as shown on Form 720, 2290, or 8849)

Taxpayer identification number

Type of Return and Return Information (Whole dollars only)

Part I

Check the box for the return for which you are using this Form 8453-EX and enter the applicable amount from the return. If you check

the box on lines 1a, 2a, or 3a, below, and the amount on that line for the return for which you are filing this form was blank, leave lines

1b, 1c, 2b, or 3b, whichever is applicable, blank (do not enter -0-). However, if you entered -0- on the return, enter -0- on the

applicable line below. Do not complete more than one line in Part I.

1a Form 720 check here

b Balance due, if any (Form 720, Part III, line 10) .

▶

c Overpayment, if any (Form 720, Part III, line 11)

2a Form 2290 check here

b Balance due (Form 2290, line 6)

▶

3a Form 8849 check here

b Total refund (from Schedules 1, 2, 3, 5, 6, or 8)

▶

Caution. For line 3b, Schedules 2, 3, 5, and 8 cannot be combined with any other schedules. File a separate Form 8453-EX for each

schedule.

Declaration of Taxpayer (see instructions)

Part II

I am requesting a refund on Form 720 or Form 8849.

I authorize the U.S. Treasury and its designated Financial Agent to initiate an electronic funds withdrawal (direct debit) entry

to the financial institution account indicated in the tax preparation software for payment of the federal taxes owed for the

return indicated on lines 1a or 2a, and the financial institution to debit the entry to this account. To revoke a payment, I must

contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than two business days prior to the payment

(settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to

receive confidential information necessary to answer inquiries and resolve issues related to the payment.

Under penalties of perjury, I declare that the information I have given my electronic return originator (ERO), transmitter, and/or intermediate service provider (ISP) and the

amounts in Part I above agree with the amounts on the corresponding return. To the best of my knowledge and belief, the return is true, correct, and complete. I consent to

my ERO, transmitter, and/or ISP sending the return, this declaration, and accompanying schedules and statements to the IRS. I also consent to the IRS sending my ERO,

transmitter, and/or ISP an acknowledgment of receipt of transmission and an indication of whether or not the return is accepted and, if rejected, the reason(s) for the

rejection. If the processing of the return or refund is delayed, I authorize the IRS to disclose to my ERO, transmitter, and/or ISP the reason(s) for the delay, when the refund

was sent.

Sign

Here

Taxpayer’s signature

Date

Declaration of Electronic Return Originator (ERO) and Paid Preparer (see instructions)

Part III

I declare that I have reviewed the return indicated above and that the entries on Form 8453-EX are complete and correct to the best of my knowledge. If I am only a

collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the return. The taxpayer will have signed this form

before I submit the return. I will give the taxpayer a copy of all forms and information to be filed with the IRS, and have followed all other requirements in Pub. 3112, IRS

e-file Application and Participation, and Pub. 4163, Modernized e-File (MeF) Information for Authorized IRS e-file Providers for Business Returns. If I am also the paid

preparer, under penalties of perjury I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and

belief, it is true, correct, and complete. This paid preparer declaration is based on all information of which I have any knowledge.

Date

Check if

Check if self-

ERO’s SSN or PTIN

ERO’s

also paid

employed

ERO’s

preparer

signature

Use

Firm’s name (or yours

EIN

Only

if self-employed),

address, and ZIP code

Phone no.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is

true, correct, and complete. This declaration is based on all information of which I have any knowledge.

Print/Type preparer’s name

Preparer’s signature

Date

PTIN

Paid

Check

self-employed

Preparer

Firm’s name

Firm's EIN

Use Only