Fillable Form 13775 - Tax Check Waiver (Page 2 of 2) in pdf

Form 13775 - Tax Check Waiver Page 2

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OMB Number

Tax Check Waiver

1545-11791

Applicant Address and Signature

I request and authorize the IRS' Office of Governmental Liaison and Disclosure to release tax return and any relevant information necessary to respond

to the questions on page one to the appropriate IRS officials. To help the IRS find my tax records, I am voluntarily giving the following information (type

or print your information).

Applicant name

Applicant Social Security Number

Home address

City

State

ZIP code

Home telephone number (include area code)

Business/Work telephone number (include area code)

Applicant signature

Date signed

(Signature of the applicant authorizing the disclosure of

(This consent is valid only if received by the IRS within 120 days of

confidential tax information.)

this date.)

If married and filing a Joint Return (Spouse must complete the following information)

Spouse's name

Spouse's Social Security Number

Spouse's signature

Date signed

(If married and filing a Joint Return - Spouse's Signature is required.)

(This consent is valid only if received by the IRS within 120 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 you 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.

13775

Department of the Treasury - Internal Revenue Service

Form

(Rev. 11-2012) Catalog Number 48048G