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