Form 8655 - Reporting Agent Authorization

8655
Reporting Agent Authorization
Form
OMB No. 1545-1058
(Rev. November 2009)
Department of the Treasury
Internal Revenue Service
Taxpayer
1a
Name of taxpayer (as distinguished from trade name)
2
Employer identification number (EIN)
1b
Trade name, if any
4 If you are a seasonal employer,
check here
3
Address (number, street, and room or suite no.)
5
Other identification number
City or town, state, and ZIP code
6
Contact person
7 Daytime telephone number
8
Fax number
Reporting Agent
9
Name (enter company name or name of business)
10
Employer identification number (EIN)
11
Address (number, street, and room or suite no.)
City or town, state, and ZIP code
12
Contact person
13 Daytime telephone number
14
Fax number
Authorization of Reporting Agent To Sign and File Returns
15
Use the entry lines below to indicate the tax return(s) to be filed by the reporting agent. Enter the beginning year of annual tax returns or
beginning quarter of quarterly tax returns. See the instructions for how to enter the quarter and year. Once this authority is granted, it is
effective until revoked by the taxpayer or reporting agent.
940
941
940-PR
941-PR
941-SS
943
945
943-PR
944
944-PR
944-SS
1042
CT-1
Authorization of Reporting Agent To Make Deposits and Payments
16
Use the entry lines below to enter the starting date (the first month and year) of any tax return(s) for which the reporting agent is authorized
to make deposits or payments. See the instructions for how to enter the month and year. Once this authority is granted, it is effective until
revoked by the taxpayer or reporting agent.
940
941
943
944
945
720
1041
1042
1120
CT-1
990-PF
990-T
Disclosure of Information to Reporting Agents
17a
Check here to authorize the reporting agent to receive or request copies of tax information and other communications from the IRS related
to the authorization granted on line 15 and/or line 16
b
Check here if the reporting agent also wants to receive copies of notices from the IRS
Form W-2 Series or Form 1099 Series Disclosure Authorization
18a
The reporting agent is authorized to receive otherwise confidential taxpayer information from the IRS to assist in responding to certain IRS
notices relating to the Form W-2 series information returns. This authority is effective for calendar year forms beginning
.
b
The reporting agent is authorized to receive otherwise confidential taxpayer information from the IRS to assist in responding to certain IRS
notices relating to the Form 1099 series information returns. This authority is effective for calendar year forms beginning
.
State or Local Authorization
19
Check here to authorize the reporting agent to sign and file state or local returns related to the authorization granted on line 15 and/or line 16
Authorization Agreement
I understand that this agreement does not relieve me, as the taxpayer, of the responsibility to ensure that all tax returns are filed and that all deposits and payments are made. If line
15 is completed, the reporting agent named above is authorized to sign and file the return indicated, beginning with the quarter or year indicated. If any starting dates on line 16 are completed,
the reporting agent named above is authorized to make deposits and payments beginning with the period indicated. Any authorization granted remains in effect until it is revoked by the taxpayer
or reporting agent. I am authorizing the IRS to disclose otherwise confidential tax information to the reporting agent relating to the authority granted on line 15 and/or line 16, including disclosures
required to process Form 8655. Disclosure authority is effective upon signature of taxpayer and IRS receipt of Form 8655. The authority granted on Form 8655 will not revoke any Power of Attorney
(Form 2848) or Tax Information Authorization (Form 8821) in effect.
I certify I have the authority to execute this form and authorize disclosure of otherwise confidential information on behalf of the taxpayer.
Sign
Here
Signature of taxpayer
Title
Date
8655
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Form
(Rev. 11-2009)
ISA
STF XNQT1002
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