Form 8796-A - Request For Return / Information
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1Request for Return / Information
(Federal/State Tax Exchange Program - State and Local Government Use Only)
Return to
Internal Revenue Service
Disclosure Scanning Operation
Stop 93A
Post Office Box 621506
Atlanta, GA 30362-3006
I am requesting the following identified return(s) / return information under terms of the Federal / State Tax Coordination
Agreement. I understand disclosure or use of the information received for other than authorized tax administrative purposes
is subject to criminal and civil liabilities under sections 7213 and 7431 of the Internal Revenue Code.
1. Name of Taxpayer
SSN / ElN
Address
2. Information Requested
Tax periods
Type of return forms
Copy of return(s)
Yes
No
Check the appropriate block
Transcript
Audit Workpapers
Outstanding balance of assessments including penalties and interest computed to
(date)
Other (Specify below)
3. Reason requested (Check the appropriate block)
Pending Examination
Criminal Investigation
Pending Collection Activity
Other (Specify)
1. Name of employee making request
Date request made
2. Group Manager Signature
Group Manager phone number
Division / Branch / Group
3. From (Signature l Authorized Representative)
Date signed
Telephone number
4. Requesting Agency
Agency name
Attention
Street address
Street address
City, State, ZIP code
Instructions for Form 8796-A, Request for Returns/Information under Federal/State Exchange Agreement
The form may be used by state and local tax agency personnel requesting return(s) or return information from IRS.
Complete Sections A, B and C. After signature approval, forward to the pre-printed address in Section A. State the agency's need and use for the
requested data as specifically as possible in section B-3. A general statement that it is needed for tax administration is insufficient.
Note: Do not send expedite requests or other requests that require local handling to the address in Section A. Contact your local Disclosure Office.
If the office agrees to expedite or otherwise handle your request locally, you will submit it directly to that office.
8796-A
Form
(9-2011)
Catalog Number 58558D
Department of the Treasury-Internal Revenue Service
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