Fillable Form 13775 - Tax Check Waiver (Page 2 of 2) in pdf

Page 2

Applicant Address and Signature

I request and authorize the IRS' Office of Governmental Liaison and Disclosure to release tax return and any relevant information necessary to respond

to the questions on page one to the appropriate IRS officials. To help the IRS find my tax records, I am voluntarily giving the following information (type

or print your information).

Applicant name

Applicant Social Security Number

Home address

City

State

ZIP code

Home telephone number (include area code)

Business/Work telephone number (include area code)

Applicant signature

Date signed

(Signature of the applicant authorizing the disclosure of

(This consent is valid only if received by the IRS within 120 days of

confidential tax information.)

this date.)

If married and filing a Joint Return (Spouse must complete the following information)

Spouse's name

Spouse's Social Security Number

Spouse's signature

Date signed

(If married and filing a Joint Return - Spouse's Signature is required.)

(This consent is valid only if received by the IRS within 120 days of

this date.)

Privacy Act Statement

The Privacy Act of 1974 requires that when we ask you information about yourself, we state our legal right to do so, tell you why we are asking for it, and how it will

be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory. Our legal

right to ask you for the information is 5 U.S.C. 301 and Executive Order (E.O.) 9397. We are asking for this information to determine your suitability as an employee

(direct hire or contracted), consultant or advisor of the Internal Revenue Service.

If you do not provide us with this information, it may adversely affect our ability to consider you. Any adverse information will be shared with the appropriate IRS

office(s) and may be disclosed to other federal agencies as required by law. Requesting you Social Security Number, under authority E.O. 9397, is also voluntary and

no right, benefit, or privilege provided by law will be denied as a result of refusal to disclose it.

Paperwork Reduction Act Notice

We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to give us the information. We need it to ensure

that you are complying with these laws and to allow us to figure and collect the right amount of tax. You are not required to provide the information requested on a form

that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be

retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential,

as required by section 6103.The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is shown

below. The estimated burden for all other taxpayers who file this form is approved under OMB control number 1545-1791.

Preparing, copying, assembling, and sending the form to the IRS …………………….. 1 hour., 30 mins.

If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can write

to: Internal Revenue Service, 1111 Constitution, Ave, NW, Washington, DC 20224. Do not send the form to this address. Instead, see the return address on the form.

13775

Catalog Number 48048G

Form

(Rev. 1-2015)

Form 13775 - Tax Check Waiver Page 2

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