Tax Authorization IRS APL

TAX AUTHORIZATION IRS APL

Taxpayer Information

Entity Type

Indicate the taxpayer's entity type by checking the applicable box. If multiple apply, select all that accurately describe the taxpayer.

Individual / Sole Proprietor

C Corporation

S Corporation

Partnership

Trust / Estate

Limited Liability Company (LLC)

Other:

Taxpayer Identification Number (TIN)

Enter the appropriate taxpayer identification number. Provide only one number of the type that applies.

Tax Matters and Periods

Tax form(s) and matter(s) authorized (e.g., Form 1040, Form 941, Examination, Collections, Account Transcripts). Provide specific forms, matters, and periods.

Periods covered: From through . If left blank, this authorization applies to all periods for the matters specified above.

Scope of Authorization

The taxpayer authorizes the Internal Revenue Service to disclose and discuss the specified tax information to the person(s) or organization(s) named in this form and to permit the named designee(s) to receive copies of tax returns, account transcripts, and other tax records as indicated below.

Inspect and obtain tax transcripts and account information

Receive copies of tax returns and return information

Represent and communicate with tax authorities on my behalf regarding the matters specified

Limited authorization described here:

Authorized Representative / Third-Party Designee

Provide information for the individual or organization authorized to receive the taxpayer's information or represent the taxpayer.

Duration and Revocation

This authorization is effective immediately upon signature unless a later effective date is specified. The taxpayer may revoke this authorization at any time by providing a written notice to the Internal Revenue Service and the representative; revocation does not apply to disclosures already made in reliance upon this authorization prior to receipt of revocation.

Effective Date (if other than signature date):

Expiration Date (if any): — if left blank, authorization remains in effect until revoked.

Certification and Perjury Statement

Under penalties of perjury, I certify that I am the taxpayer or an individual authorized to execute this form on behalf of the taxpayer, that the information provided on this form is true, correct, and complete, and that I authorize the disclosure of the taxpayer's tax information as specified herein.

I acknowledge and agree to the following (initial or check each applicable item):

1. Authorization includes the release of return information, account transcripts, and other tax records necessary for the matters specified.

2. The designated representative may discuss and receive information but may not change tax return entries or execute binding agreements unless expressly authorized in writing.

3. This authorization does not authorize the representative to endorse or negotiate refunds unless explicitly indicated in the limited authorization field above.

4. I understand that providing false or misleading information in connection with this authorization may subject me to penalties under applicable law, including penalties for perjury.

By signing below, I certify under penalties of perjury that I am authorized to execute this document and that the statements made herein are true and correct to the best of my knowledge.

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