Form 4180 - Report Of Interview With Individual Relative To Trust Fund Recovery Penalty Or Personal Liability For Excise Taxes Page 4

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Page 4
Additional Information
Section VIII - Signatures
I declare that I have examined the information given in this interview and to the best of my knowledge and belief, it is true, correct, and
complete.
Signature of person interviewed
Date
Signature of Interviewer
Date
Date copy of completed interview form given to person interviewed
Interview Handouts
(''X'' if given or explain why not in case history.)
Notice 609, Privacy Act Notice
Notice 784, Could You be Personally Liable for Certain Unpaid Federal Taxes?
4180
Form
(Rev. 8-2012)
Catalog Number 22710P

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