Form 13551 - Application To Participate In The Irs Acceptance Agent Program Page 3
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13551
Department of the Treasury - Internal Revenue Service
OMB Number
Form
Continuation Sheet for Additional Authorized Representatives
1545-1896
(Rev. August 2014)
(see Form 13551 instructions)
Legal Name of the Business (Page 1, Line 2 (and 11, if applicable))
Business EFIN
Business EIN
Business location address
Street
City/County
State/Country
ZIP Code/Foreign Postal Code
Information and Signature of Additional Authorized Representative
Professional Status of
5. Name and PTIN of Authorized Representative of
6. Date of birth
7. Social Security Number (SSN) or Taxpayer
Authorized
the Business (first, middle, last, PTIN)
(month, day, year)
Identification Number (ITIN)
Representative (Line 5)
Tax Preparer
8. Home address (street, city/county, state/country,
9. Check the appropriate box
10. Have you ever been assessed any preparer
CPA*
and ZIP code/foreign postal code) of individual
penalties, been convicted of a crime, failed to
U.S. Citizen
file personal tax returns, or pay tax liabilities,
listed on Line 5
Attorney*
or been convicted of any criminal offense
U.S. Resident Alien*
Enrolled Agent*
under the U.S. Internal Revenue laws
Nonresident Alien*
Yes
No
number
*Attach copy of green card
(Please attach an explanation for a “Yes”
Other
or visa if residing in the U.S.
response.)
*See instructions for
proof requirements
13. Business telephone number
Fax number
14. Mailing address of the Business if different from the location address on line 12
(
)
(
)
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.
Signature of Authorized Representative
Name and title of Authorized Representative from line 5 (type or print)
Date
Information and Signature of Additional Authorized Representative
Professional Status of
5. Name and PTIN of Authorized Representative of
6. Date of birth
7. Social Security Number (SSN) or Taxpayer
Authorized
the Business (first, middle, last, PTIN)
(month, day, year)
Identification Number (ITIN)
Representative (Line 5)
Tax Preparer
8. Home address (street, city/county, state/country,
9. Check the appropriate box
10. Have you ever been assessed any preparer
CPA*
and ZIP code/foreign postal code) of individual
penalties, been convicted of a crime, failed to
U.S. Citizen
file personal tax returns, or pay tax liabilities,
listed on Line 5
Attorney*
or been convicted of any criminal offense
U.S. Resident Alien*
Enrolled Agent*
under the U.S. Internal Revenue laws
Nonresident Alien*
Yes
No
number
*Attach copy of green card
(Please attach an explanation for a “Yes”
Other
or visa if residing in the U.S.
response.)
*See instructions for
proof requirements
13. Business telephone number
Fax number
14. Mailing address of the Business if different from the location address on line 12
(
)
(
)
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.
Signature of Authorized Representative
Name and title of Authorized Representative from line 5 (type or print)
Date
Privacy Act and 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. 8-2014)
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