Form 13775 TaxCheck Waiver

Tax Check Waiver

OMB No. 1545-1791

I am submitting this waiver to permit the Internal Revenue Service (IRS) to release information about me which would otherwise be
confidential. This information will be used in connection with my application for appointment to membership in the IRS Advisory
Committee/Council identified below. This information will also be used to verify returning members' continuing tax compliance with the
terms of this waiver as a condition for continued membership. This waiver is made pursuant to 26 U.S.C. 6103(c).
Name of applicant

Enter the name of the IRS Advisory Committee/Council for which
you are applying or continuing in membership

1. Have you failed to timely file a Federal income tax return by the required due date
(determined with regard to any extention(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 extentions] 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.)

Check One Box

Yes

No

2. Have you failed to pay any tax, penalty, or interest liability during the current or last three
calendar years within ten (10) days of the date on which the IRS gave notice of the amount
due and requested payment?

Yes

No

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

Yes

No

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

Yes

No

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.)

Names and addresses shown on last three returns (if different from the information provided in the Applicant Address and Signature
section on page two).
Year

1.

20

2.

20

3.

20

Name(s)

Form 13775 (Rev. 12-2010)

Address

Catalog Number 48048G

www.irs.gov

Department of the Treasury- Internal Revenue Service

If you are self-employed, provide the Business Names and Employer Identification Numbers (EIN) associated with any self-employment
for the past three years
Business Name

Employer Identification Number

Applicant Address and Signature
I am signing this waiver to permit the Internal Revenue Service (IRS) to release information about me which would otherwise be confidential. This
information will be used in connection with my application for/appointment to/membership in the IRS Advisory Committee/Council. This waiver is made
pursuant to 26 U.S.C. 6103(c).
I request that the IRS' Office of Governmental Liaison and Disclosure release the following information to the appropriate IRS officials.
I authorize the IRS to release any additional relevant information necessary to respond to the question above. To help the IRS find my tax records, I am
voluntarily giving the following information (please type or print).

Applicant name

Social Security Number

Home address
City

State

ZIP code

Home telephone number

Business/Work telephone number

Applicant signature

Date signed

(Signature of the applicant authorizing the disclosure of
confidential tax information.)

(This consent is valid only if received by the IRS within 120 days of
this date.)

If married and filing a Joint Return (Spouse must complete the following information)
Spouse's name

Social Security Number

Spouse's signature

Date signed

(If married and filing a Joint Return - Spouse's Signature is required.)

(This consent is valid only if received by the IRS within 120 days of
this date.)

Privacy Act Statement
The Privacy Act of 1974 requires that when we ask you information about yourself, we state our legal right to do so, tell you why we are asking for it, and
how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a
benefit, or mandatory. Our legal right to ask you for the information is 5 U.S.C. 301 and Executive Order (E.O.) 9397. We are asking for this information
to determine your suitability as an employee (direct hire or contracted), consultant or advisor of the Internal Revenue Service.
If you do not provide us with this information, it may adversely affect our ability to consider you. Any adverse information will be shared with the
appropriate IRS office(s) and may be disclosed to other federal agencies as required by law. Requesting you Social Security Number, under authority
E.O. 9397, is also voluntary and no right, benefit, or privilege provided by law will be denied as a result of refusal to disclose it.
Form 13775 (Rev. 12-2010)

Catalog Number 48048G

www.irs.gov

Department of the Treasury- Internal Revenue Service