Form 13551 - Application To Participate In The Irs Acceptance Agent Program - 2011 Page 3
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43
Page
OMB Number
Continuation Sheet for Additional Authorized Representatives
13551)
(Form
1545-1896
Department of the Treasury
See Form 13551 instructions
Internal Revenue Service
Legal Name of the Business (Page 1, Line 2 (and 11, if applicable))
Business EIN
Business EFIN
Business Location Address
Number and Street
City/County
State/Country
ZIP Code/Foreign Postal Code
Information and Signature of Additional Authorized Representative
Professional Status of
5 Name and email of Authorized Representative of
6 Date of birth
7 Social Security Number (SSN) or
the Business (first, middle, last)
(month, day, year)
Taxpayer Identification Number (ITIN)
Authorized
Representative (Line 5)
Tax Preparer
9 Check the
8 Home address (street, city/county, state/country,
10 Have you ever been assessed any
CPA*
appropriate box
preparer penalties, been convicted
and ZIP code/foreign postal code) of individual
listed on Line 5.
of a crime, failed to file personal
Attorney*
U.S. Citizen
tax returns, or pay tax liabilities, or
Enrolled Agent*:
U.S. Resident Alien*
been convicted of any criminal
offense under the U.S. Internal
Nonresident Alien*
No.
Revenue laws?
No
*Attach copy of green
Yes
Other
card or visa if residing
*See instructions for
(Please attach an explanation for a
in the U.S.
proof requirements
“Yes” response.)
Business
13
Telephone:
Fax Number:
14 Mailing address of the Business (if different from the location address at top of page)
(
)
(
)
Number and Street
City/County
State/Country
ZIP Code/Foreign Postal Code
Email:
Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the
information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the
Revenue Procedure for Acceptance Agents and related publications each year of our participation.
Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further
understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance
Agent Program. I am authorized to make and sign this statement on behalf of the institution.
Name and title of Authorized Representative (type or print)
Signature of Authorized Representative
Date
Information and Signature of Additional Authorized Representative
Professional Status of
6 Date of birth
7 Social Security Number (SSN) or
5 Name and email of Authorized Representative of
(month, day, year)
Taxpayer Identification Number (ITIN)
Authorized
the Business (first, middle, last)
Representative (Line 5)
Tax Preparer
9 Check the
8 Home address (street, city/county, state/country,
10 Have you ever been assessed any
appropriate box
CPA*
and ZIP code/foreign postal code) of individual
preparer penalties, been convicted
listed on Line 5.
of a crime, failed to file personal
Attorney*
U.S. Citizen
tax returns, or pay tax liabilities, or
been convicted of any criminal
Enrolled Agent*:
U.S. Resident Alien*
offense under the U.S. Internal
Nonresident Alien*
No.
Revenue laws?
Other
*Attach copy of green
Yes
No
card or visa if residing
*See instructions for
(Please attach an explanation for a
in the U.S.
proof requirements
“Yes” response.)
Business
14 Mailing address of the Business (if different from the location address at top of page)
13
Telephone: Fax Number:
(
)
(
)
Number and Street
City/County
State/Country
ZIP Code/Foreign Postal Code
Email:
Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the
information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the
Revenue Procedure for Acceptance Agents and related publications each year of our participation.
Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further
understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance
Agent Program. I am authorized to make and sign this statement on behalf of the institution.
Date
Name and title of Authorized Representative (type or print)
Signature of Authorized Representative
Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your response is voluntary. You are
not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or
records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by code section 6103. The estimated average time to complete this form is 30 minutes. If you have comments
concerning the accuracy of this time estimate or suggestions for making this form simpler, we will be happy to hear from you. You can write to the Internal Revenue Service,
Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224. Do NOT send this form to this address. Instead, enclose
it with the magnetic tape and send it to the Service Center to which you submit your tapes or send it to the transmission reception site that received your transmitted returns.
13551
Catalog Number 38262Q
Form
(Rev. 11-2011)
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