Certified Professional Employer Organization Customer Reporting Agreement Page 3


Form 8973 (5-2017)
CPEO Consent to Disclosure of Tax Information
To maintain certification, a Certified Professional Employer Organization (CPEO) must complete this
consent to disclose tax information to the customer reported on Form 8973 and send it to the IRS.
By signing, dating, and entering my employer identification number (EIN) at the bottom of this
page, I hereby consent, to the extent necessary to carry out the purposes of the CPEO program, to
the IRS disclosing, to the customer named below, information from my employment tax returns (for
example, Forms 940 and 941) filed with respect to the customer named below. This consent also
covers the disclosure of any information regarding my obligations to report, deposit, and pay federal
employment taxes for the customer named below. I also consent to the disclosure of information
about my certification, regardless of year.
The customer named below is authorized to inspect and/or receive the confidential tax information
identified above for the tax forms and tax periods listed below. See the instructions for details on
how to report the tax periods.
Customer’s name (from Form 8973, Part 2)
Customer’s EIN (from Form 8973, Part 2)
Tax Form Number
Year(s) or Period(s)
(940, 941, 943, CT-1)
I understand that the information to be disclosed is generally confidential under the laws applicable to the IRS and that the customer receiving
the information is not bound by these laws and may use the information for any purpose as permitted by other federal laws and/or state laws. I
certify that I have the authority to execute this consent.
Sign your
Print your
name here
name here
Print your
title here
CPEO’s name


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