Tax Transcript Form

TAX TRANSCRIPT FORM

Complete this form to request and authorize release of tax transcript information for the taxpayer identified below. Provide accurate taxpayer identification and indicate the transcript type(s) requested. This form constitutes a limited authorization to disclose tax information as described in the Authorization section.

Taxpayer Information

Entity Type (select applicable)

Individual / Sole Proprietor C Corporation S Corporation Partnership Trust / Estate LLC Other

Taxpayer Identification

Check which identification number is provided and enter the number in the corresponding field.

Transcript(s) Requested

Select the type(s) of transcript requested. Check all that apply.

Tax Return Transcript (tax return information) Tax Account Transcript (account transactions) Record of Account (combination of return and account) Wage and Income Transcript Verification of Nonfiling Other (describe)

Tax Periods Requested

Enter the tax years or period of returns/accounts requested. For individual years enter four-digit years.

Third-Party Recipient (if applicable)

If transcripts are to be disclosed to a third party, provide recipient information below. If transcripts are only for the taxpayer, leave blank.

Preferred delivery method: Mail Fax Email

Authorization to Disclose

I authorize the tax administration to disclose the transcript information requested above to the recipient named in this form. This authorization applies only to the transcript types and tax periods expressly listed. I understand that tax transcripts may contain confidential tax return information and that this authorization does not authorize disclosure of any information beyond the scope described herein.

This authorization is effective upon receipt and remains valid for 90 days from the date signed below unless earlier revoked in writing by the taxpayer. A photocopy or electronic copy of this form has the same effect as the original.

Certification and Perjury Statement

Under penalties of perjury, I declare that I have examined this form and, to the best of my knowledge and belief, the information provided is true, correct, and complete. By signing below I certify the following:

1. I am the taxpayer named on this form or I am authorized to sign on behalf of the taxpayer and have the authority to request and receive the requested transcripts.

2. The taxpayer identification number provided on this form (SSN or EIN) is correct to the best of my knowledge.

3. I understand that knowingly making a false statement on this form may subject me to penalties under applicable law, including penalties for perjury.

4. I hereby request and authorize disclosure of the transcript(s) specified on this form for the periods indicated.

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