Form 13551 - Application To Participate In The Irs Acceptance Agent Program - 2011 Page 4
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Information and Signature of Additional Authorized Representative
Page
5 Name and email of Authorized Representative of
6 Date of birth
7 Social Security Number (SSN) or
Professional Status of
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
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
No.
Nonresident Alien*
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
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
8 Home address (street, city/county, state/country,
9 Check the
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
Enrolled Agent*:
been convicted of any criminal
U.S. Resident Alien*
offense under the U.S. Internal
No.
Nonresident Alien*
Revenue laws?
Other
*Attach copy of green
No
Yes
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
Names and Contact Information for Primary and Alternate Contacts at the business location listed above. (Complete only if primary and
alternate contacts for this business location are not already listed as the primary and alternate contacts on page 1, line 16 of the attached
Form 13551.
Complete information for alternate contact if not listed on attached Form 13551
16
Complete information for primary contact if not listed on attached Form 13551
Name (first, middle initial, last) and Title
Name (first, middle initial, last) and Title
(
)
(
)
(
)
(
)
Phone No.
Fax No:
Email:
Phone No.
Fax No:
Email:
Signature of Principal, Partner or Owner of Business
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 Principal, Partner or Owner (type or print)
Signature of Principal, Partner or Owner
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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