Form 8569 - Geographic Availability Statement
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1OMB No.
Geographic Availability Statement
1545-0973
Paperwork Reduction Act Notice: This form is used in considering applicants
You are not required to provide the information requested on a form that is
for the Senior Executive Service Candidate Development Program and other
subject to the Paperwork Reduction Act unless the form displays a valid OMB
executive positions. Your response is voluntary; however, your failure to
control number. Books or records relating to a form or its instructions must be
provide this information could effect your consideration for this program. This
retained as long as their contents may become material in the administration of
signed statement will remain the minimum area of availability and will be used
any Internal Revenue law. Generally, tax returns and return information are
for future job placement consideration. Employees must secure the approval of
confidential, as required by Internal Revenue Code Section 6103.
the Executives Resources Board for any change in their area of availability.
Based upon your experience and prior assignments, you will be considered for
The time needed to complete the geographic availability statement is twenty
any Board covered position located in the area of your geographic availability.
minutes. If you have comments concerning the accuracy of this time estimate
The cities listed below are not all inclusive but are intended to provide you with
or suggestions for making this form simpler, we would be happy to hear from
a general idea of where IRS offices do or may exist.
you. You can write to Internal Revenue Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6406,
Washington, DC 20224. DO NOT send the completed Geographic Availability
Statement to this office.
Availability for Headquarter Operations in Washington, DC and/or Atlanta is required.
I am available for all locations.
I am available for only those locations marked below. (You must mark all locations for which you are
available. If you are only available for Washington, DC and/or Atlanta, you must mark which one or both.)
Atlanta GA
Fresno CA
Memphis TN
Andover MA
Ft. Lauderdale FL
Nashville TN
Austin TX
Greensboro NC
Newark NJ
Baltimore MD
Hartford CT
New Orleans LA
Boston MA
Houston TX
Oakland CA
Brookhaven NY
Indianapolis IN
Ogden UT
Brooklyn NY
Jacksonville FL
Philadelphia PA
Chicago IL
Kansas City MO
Phoenix AZ
Cincinnati OH
Laguna Niguel CA
San Francisco CA
Dallas TX
Los Angeles CA
Seattle WA
Denver CO
Manhattan NY
St. Louis MO
Detroit MI
Martinsburg WV
St. Paul MN
Washington DC Metropolitan Area
Remarks
Name
(Please type)
Signature
Date signed
Return completed form to
Internal Revenue Service
Attn: Executive Services Division
OS:HC:S Room 3511
1111 Constitution Ave., NW
Washington, DC 20224
8569
Form
(Rev. 4-2006)
Catalog Number 63618S
Department of the Treasury-Internal Revenue Service
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