Form 8821 - Tax Information Authorization
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68821
OMB No. 1545-1165
Tax Information Authorization
For IRS Use Only
Form
Received by:
Information about Form 8821 and its instructions is at
Name
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(Rev. October 2012)
Telephone
Do not sign this form unless all applicable lines have been completed.
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Department of the Treasury
Function
To request a copy or transcript of your tax return, use Form 4506, 4506-T, or 4506T-EZ.
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Internal Revenue Service
Date
1 Taxpayer information. Taxpayer must sign and date this form on line 7.
Taxpayer name and address (type or print)
Taxpayer identification number(s)
Daytime telephone number
Plan number (if applicable)
2 Appointee. If you wish to name more than one appointee, attach a list to this form.
CAF No.
Name and address
PTIN
Telephone No.
Fax No.
Check if new: Address
Telephone No.
Fax No.
3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information for the tax matters listed on this
line. Do not use Form 8821 to request copies of tax returns.
(a)
(b)
(c)
(d)
Type of Tax
Tax Form Number
Year(s) or Period(s)
Specific Tax Matters (see instr.)
(Income, Employment, Payroll, Excise, Estate,
(1040, 941, 720, etc.)
(see the instructions for line 3)
Gift, Civil Penalty, etc.) (see instructions)
4 Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific
use not recorded on CAF, check this box. See the instructions. If you check this box, skip lines 5 and 6 .
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5 Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):
a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing
basis, check this box
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Note. Appointees will no longer receive forms, publications and other related materials with the notices.
b If you do not want any copies of notices or communications sent to your appointee, check this box
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6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior
authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want
to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect
and check this box .
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To revoke this tax information authorization, see the instructions.
7 Signature of taxpayer. If signed by a corporate officer, partner, guardian, executor, receiver, administrator, trustee, or
party other than the taxpayer, I certify that I have the authority to execute this form with respect to the tax matters and tax
periods shown on line 3 above.
IF NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.
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DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.
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Signature
Date
Print Name
Title (if applicable)
PIN number for electronic signature
8821
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 10-2012)
Cat. No. 11596P
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