Fill and Sign the Request Copy Form

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 2. CURRENT NAME AND ADDRESS 3. IF INFORMATION IS TO BE MAILED TO SOMEONE ELSE, SHOW THE THIRD PARTY'S NAME AND ADDRESS 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 6. SPOUSE'S NAME AND SOCIAL SECURITY NUMBER AS SHOWN ON TAX FORM Spouse's Name 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 administrative 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. Name Signature Date Telephone