Fill and Sign the Form 4506

FORM 4506 REQUEST FOR COPY OF TAX FORM OR INDIVIDUAL INCOME TAX ACCOUNT INFORMATION (OMB Clearance Number 1545-0429) 1. NAME OF TAXPAYER AS SHOWN ON TAX FORM:[FIELD 12] 2. CURRENT NAME AND ADDRESS: [FIELD 11] [FIELD 14] [FIELD 15] 3. IF INFORMATION IS TO BE MAILED TO SOMEONE ELSE, SHOW THE THIRD PARTY'S NAME AND ADDRESS: [FIELD 7] [FIELD 3] [FIELD 4] [FIELD 5] 4. IF NAME IN THIRD PARTY'S RECORDS DIFFERS FROM ITEM 1 ABOVE, SHOW HERE (See instructions for item 3): 5. SOCIAL SECURITY OR EMPLOYER IDENTIFICATION NUMBER AS SHOWN ON TAX FORM: [FIELD 23] 6. SPOUSE'S SOCIAL SECURITY NUMBER AS SHOWN ON TAX FORM: Spouse's Name: [FIELD 22] Spouse's SS No.: 7. TAX FORM NUMBER (Form 1041, 941, etc.): 8. TAX PERIOD(s) (No more than 4 per request): 9. AMOUNT DUE (Make check payable to IRS):$ NOTE: Full payment must accompany your request. 10. DESCRIBE WHAT YOU WANT (Check only one box): $5.00 each [ ] Copy of tax return and all attachments (including Forms W-2) [ ] NOTE: If you need these copies certified for court or administra- tive proceedings, check here also. $2.50 each [ ] Tax account information only (Do not use for income averaging) $2.50 each [ ] Form 1040A or Form 1040EZ verification only. _________________________________________________________________ PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE We ask for this information to carry out the Internal Revenue laws of the United States. We need the information to gain access to your return in our files and properly respond to your request. If you do not furnish the information, we may not be able to fill your request._________________________________________________________________ ___________________________________ DATE: February 15, 20___ Signature: [FIELD 11] Telephone: [FIELD 19]