Form 12339 - Internal Revenue Service Advisory Council Membership Application Page 2

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PART VI – Applicant Acknowledgement
I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.
Applicant signature
Date signed
PRIVACY ACT STATEMENT
The Privacy Act of 1974 requires that when we ask you for 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 for the information is Public Law 92-463 and Executive Order
(E.O.) 9397. We are asking for the information in order to perform Federal income tax, FBI, and practitioner checks as required of all
members and applicants to the IRS Advisory Council.
Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership
in the IRS Advisory Council. Requesting your social security number, which is solicited under authority of 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. However, not providing all or any
part of the information may limit consideration of your application.
12339
Form
(Rev. 3-2011)
Catalog Number 28320P
Department of the Treasury–Internal Revenue Service

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