2
Form 23 (Rev. 4-2012)
Page
6
Do you have a Centralized Authorization File (CAF) number?
Yes
No
If “Yes”, enter all CAF numbers assigned to you (attach additional pages, if necessary):
7
Yes
No
Have you been sanctioned by a federal or state licensing authority?
Has any application you filed with a court, government department,
8
commission, or agency for admission to practice ever been denied?
Yes
No
9
Have you been convicted of a tax crime or any felony?
Yes
No
Have you been permanently enjoined from preparing tax returns, or
10
representing others before the IRS?
Yes
No
NOTE: If you answered “Yes” to question 7, 8, 9 or 10, please describe on a separate page, the matter, including the date of
when the matter occurred, and provide any additional information about the matter that you would like us to consider.
11
Are you a CPA?
If “Yes”, enter the states where you are licensed to practice.
Yes
No
12
Are you an Attorney?
If “Yes”, enter the states where you are licensed to practice.
Yes
No
13
Are you a Registered Tax Return Preparer (RTRP)?
Yes
No
Part 2. Sign here
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature
Date
23
Form
(Rev. 4-2011)
Filling out this form:
It is important to answer all questions on the form. Failure to answer any questions or sign the form could result in processing delays.
An intentionally false statement or omission identified with your application is a violation of Circular 230 10.51(a)(4) and 18 U.S.C. 1001
and may be grounds for suspension or disbarment from practice.