Form 8554 - Application For Renewal Of Enrollment To Practice Before The Internal Revenue Service Page 2

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Form 8554 (Rev. 4-2012)

Page

Yes

Do you have a Centralized Authorization File (CAF) number?

If Yes, enter all CAF numbers assigned to you (attach additional pages, if necessary):

Do you have an Employer Identification Number (EIN)?

Yes

If Yes, enter all EINs, business names, and addresses below (attach additional pages, if necessary):

EIN

Business Name

Business Address

Since you have become an enrolled agent or your last renewal of enrollment (whichever is later):

Have you been sanctioned by a federal or state licensing authority?

Yes

Has any application you filed with a court, government department,

commission, or agency for admission to practice ever been denied?

Yes

Have you been convicted of a tax crime or any felony?

Have you been permanently enjoined from preparing tax returns, or

representing other before the IRS?

Yes

NOTE: If you answered yes to question 7, 8, 9 or 10, please describe on a separate page, the matter, including the date of

when the matter occurred, and provide any additional information about the matter that you would like us to consider.

Are you a CPA?

If Yes, enter the states where you are licensed to practice.

Yes

Are you an Attorney?

If Yes, enter the States where you are licensed to practice.

Yes

Are you a Registered Tax Return Preparer (RTRP)?

Yes

Part 3. Sign here

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.

PTIN

Signature

Date

8554

Form

(Rev. 2-2011)