Fillable Form 13775 - Tax Check Waiver printable pdf download

Form 13775 - Tax Check Waiver

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OMB Number

Tax Check Waiver

1545-11791

The purpose of this form is to permit the Internal Revenue Service (IRS) to release information about the applicant which would

otherwise be confidential. This information will be used in connection with my application for appointment to membership in one of the

IRS Advisory Committee/Council. This waiver is made pursuant to 26 U.S.C. 6103(c).

Name of applicant

Name of the IRS Advisory Committee/Council for which you are

applying or continuing in membership

Internal IRS USE ONLY: Completed by the IRS Advisory Committee/Council Program Manager

Name and title of the authorized official

You are required to answer all the following questions:

Check Only One Box

1. Have you failed to timely file a Federal income tax return by the required due date (determined

Yes

with regard to any extension(s) of time for filing) for any of the last three years for which filing of

a return was required?

(NOTE: If the filing date [without regard to extensions] and normal processing period for the

most recent year's return has not yet elapsed on the date IRS receives this waiver, and IRS

records do not indicate a return for the most recent year, the "last three years" will mean the

three years preceding the year for which returns are currently being filed and processed.)

2. Have you failed to pay any tax, penalty, or interest liability during the current or last three

Yes

calendar years within ten (10) days of the date on which the IRS gave notice of the amount due

and requested payment

3. Are you now or have you ever been under investigation for a misdemeanor or criminal offenses

Yes

4. Have any civil penalties for fraud been assessed against you during the current or last three

Yes

calendar years

Comments (If you answered "Yes" to question 1, 2, 3, or 4, provide your explanation below. You may also use this space to address

any other tax compliance issue you believe is pertinent to this application.)

Provide the names and addresses shown on your last three tax returns (if different from the information provided in the Applicant

Address and Signature section on page two).

Year

Name(s)

Address

13775

Department of the Treasury - Internal Revenue Service

Form

(Rev. 11-2012) Catalog Number 48048G

Form 13775 - Tax Check Waiver

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