Form 10301 - Cd Encryption Code Authorization For Cp2100 972cg Notices

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Department of the Treasury - Internal Revenue Service
10301
CD Encryption Code Authorization
Form
(January 2017)
For CP2100/972CG Notices
Type or print in black ink.
1. Type of request*
Original
Revised
2. Payer information (company receiving CD)
Legal name*
Address* (street)
City*
State*
ZIP code*
3. Taxpayer Identification Number (TIN)* (9 digit EIN or SSN)
EIN
-
OR
SSN
-
-
4. Primary Company contact
Name*
Telephone number*
5. Secondary Company contact
Name*
Telephone number*
6. Personal Identification Number (PIN)* (provide a self-assigned alphanumeric 10-digit PIN)
7.
I have read the Affidavit in the Instructions on page 2 and I am authorized to sign the document on behalf of the payer*
Affidavit
Under penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct and
complete, and I have the authority to execute this form. The contact person(s) listed above is authorized to receive encryption code(s)
for CP2100/972CG Notices.
8. Official of the Company or Organization
Name* (type or print)
Signature*
Title*
Date*
*All fields marked with an asterisk (*) are required fields.
10301
Catalog Number 33392H
Form
(Rev. 1-2017)

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