Form 12339-A - Tax Check Waiver Page 2
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1
2Comments (If you answered ''Yes'' to any question on page one (1), please explain why)
I authorize the IRS to release any additional relevant information necessary to respond to the questions on page one (1).
To help the IRS find my tax records, I am voluntarily providing the following information (please type or print).
Name
Social Security Number
Home street address
City
State
ZIP Code
Home telephone number
Business/Work telephone number
Applicant signature (Signature of the applicant authorizing the disclosure of confidential tax information)
Date signed (This consent is valid only if received by the IRS within sixty (60) calendar days of this date)
If you are married and file a joint Federal tax return, your Spouse must provide the following information
Spouse's name
Social Security Number
Spouse's signature (Signature of the spouse authorizing the disclosure of confidential tax information)
Date signed (This consent is valid only if received by the IRS within sixty (60) calendar 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 your 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.
12339-A
Form
(Rev. 5-2006)
Catalog Number 28321A
Department of the Treasury-Internal Revenue Service
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