Form 13013-A Tax Check Waiver

OMB No.

Tax Check Waiver
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 applications for appointment to membership
in the Taxpayer Advocacy Panel (TAP). This information will also be used to verify returning TAP members’ continuing
tax compliance with the terms of this waiver as a condition for continued membership in the TAP. This waiver is made
pursuant to 26 U.S.C. 6103(c).
I request that the IRS' designated Local Taxpayer Advocate release the following information to the appropriate IRS
officials, including, but not limited to, the Director, Taxpayer Advocacy Panel.
Check only one
box per question
1. Have you failed to timely file a Federal tax return by the required due date (determined 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 the 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.)

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 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

5. If a return for any of the last three years was not filed, please explain why in the Comments Section
on page 2.If there was insufficient income to meet filing requirements or filing requirements were met
by filing with a foreign tax agency (e.g., Puerto Rico or the Virgin Islands), please describe the
circumstances in the Comments Section on page 2.
Names and addresses shown on last three income tax returns (If different from the information shown on page two (2)).
Year

Name(s)

Address

1. 20

2. 20

3. 20

Form

Catalog Number

www.irs.gov

Department of the Treasury-Internal Revenue Service

Provide the Business Names and Employer Identification Numbers associated with any self-employment for the past
three years.

Business Name

Employer Identification Number (EIN)

If you are married and file a joint Federal tax return, your Spouse must provide the following information

Spouse's Name

Social Security Number

Spouse's Signature (Signature of the spouse authorizing the disclosure of confidential tax information) Date
Signed (This consent is valid only if received by the IRS within sixty (60) calendar days of this date)

Comments (If you answered ''Yes'' to any question on page one (1) or would like to address any other tax
compliance issue, please explain or comment below)

I authorize the IRS to release any additional relevant information necessary to respond to the questions on page one
(1). To help the IRS find my tax records, I am voluntarily providing the following information (please type or print).
Name

Social Security Number

Home Street Address
City

State

Home Telephone Number

Business/Work Telephone

Applicant Signature (Signature of the applicant authorizing the disclosure of confidential tax information)
Date Signed (This consent is valid only if received by the IRS within sixty (60) calendar days of this date)

Form

Catalog Number

www.irs.gov

Department of the Treasury-Internal Revenue Service

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 your
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

Catalog Number

www.irs.gov

Department of the Treasury-Internal Revenue Service