Form 4419 - Application For Filing Information Returns Electronically (Fire)
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2(See Instructions on back)
IRS Use Only
OMB No.
Department of the Treasury – Internal Revenue Service
1545-0387
4419
Application for Filing Information Returns
Form
Electronically (FIRE)
(Rev. 6-2009)
or
Please type
print in BLACK ink.
1. Transmitter information
Name
Mailing Address
State
City
Zip
2. Person to contact about this request
Name
Title
Email address
Telephone number
3. Employer Identification Number (EIN)
4. Foreign Transmitter without a TIN
5. Tax year you wish to begin filing
(
electronically
Social Security Number Not Permitted)
Yes
6. Will you be using your TCC only for transmitting requests for extension of time to file?
Yes
No
7. Type of Return To Be Reported
(Check only types of forms you currently need to file)
Important: Form W-2 information is sent to the Social Security Administration (SSA) only. Do not use Form 4419 to
request authorization to file this information electronically. Contact SSA for W-2 electronic filing information at
1-800-772-6270.
Forms 1098, 1099, 3921,
Form 1042-S, Foreign Person’s
Form 8027, Employer’s Annual
3922, 5498 and W-2G
U.S. Source Income Subject to
Information Return of Tip Income
Withholding
and Allocated Tips
8. Check the appropriate box
I have or will have software which will
I have a service provider who will file
format my data into the IRS required format.
my data for me.
Note: For the forms referenced in Box 7, electronic filing does not refer to on-line fill-in forms.
Under penalties of perjury, I declare that I have examined this document, including any accompanying statements, and,
to the best of my knowledge and belief, it is true, correct, and complete.
Name (type or print)
Title
9. Person
responsible for
preparation of
tax reports
Signature
Date
4419
Catalog Number 41639J
Form
(Rev. 6-2009)
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