Form 12339-B - Information Reporting Program Advisory Committee Membership Application Page 2

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PART IV – Applicant Resume

Attach a copy of your resume, including prior Treasury and/or IRS employment. State position

, title

, and dates of employment.

(s)

Additionally, list professional credentials, membership in professional organizations, and local liaison activities with IRS, if applicable.

PART V – Other IRS Councils/Committees

Have you ever been a member of the Internal Revenue Service Advisory Council

, Art

(formerly known as Commissioner's Advisory Group)

Advisory Panel, Electronic Tax Administration Advisory Committee, Tax Exempt Advisory Committee or Information Reporting Program

Advisory Committee? If so, include name of the councils/committees and dates of membership.

Councils/Committee name

Dates of Membership

PART VI – Applicant Acknowledgement

I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.

Applicant signature

Date signed

Privacy Act Statement

The Privacy Act of 1974 requires that when we ask you for 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 for the information is Public Law 92-463 and Executive Order (E.O.) 9397. We are asking for the information

in order to perform Federal income tax, FBI, and practitioner checks as required of all members and applicants to the Advisory Council/Committee.

Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership in the IRS

Advisory Council/Committee. Requesting your social security number, which is solicited under authority of 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. However, not providing all or any part of the information may limit

consideration of your application.

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.

12339-B

Catalog Number 48518X

Form

(Rev. 4-2017)