Form 13803 Application to Participate in the Income Verification Ex

For Official Use Only
Control Number:

Department of the Treasury–Internal Revenue Service

Application to Participate in the Income
Verification Express Service (IVES) Program

Form 13803
(Rev. January 2013)

OMB Number
1545-2032

(Please read the instructions carefully before completing this Form)

Please check the type of application you are submitting:
Renewal
Add New Location
Amended
New
1. Please check the box that describes your
organization status:

Cancellation

Address Change

Reason(s) for using the IVES Program: (Select all that apply)

Government Agency

Partnership

Mortgage Services

Banking Service

Sole Proprietorship

Corporation

Background Check

Licensing Requirement

LLC

Credit Check

Other (Specify)

Other (Specify)

2. Legal name of business (Required)

3. Business Taxpayer Identification
Number (TIN) (Required)
EIN
4. Doing Business As (DBA) Name (Complete only if the business is operating under a name which is different than the
business name listed on Line 2)

5. Business Location Address* (Required)
City

Street Address

State

ZIP Code

* If more than one location, attach a separate sheet listing all locations.

6. Business Telephone Number (Required)

Fax Number (Required)

Business E-mail Address
7. Billing Address required if different from the location address on Line 5.
Street Address

City

State

ZIP Code

8. Complete the following information for the principal company official, partner or owner of business.
Company official name (first, middle initial, last)

Title

Social Security Number (Required)

Home Street Address

Telephone Number

Date of Birth (mm/dd/yyyy) (Required)

City

State

ZIP Code

E-mail Address

* If more than one principal company official, partner or owner of business, attach a separate sheet listing all principals.

9. Primary Contact Name (required if different than the principal). A contact must be available on a day to day basis to
answer IRS questions during testing and through the processing year.
Last Name

First Name

Telephone Number (Required)

E-mail Address (Required)

10a. Have you been convicted of a felony in the last 10 years?
Yes

No

(Please attach an explanation for a “Yes” response.)

10b. Are you current with your individual and business taxes, including
any corporation and employment tax obligations?
Yes

No

Catalog Number 48547A

MI

11. Income Verification Express Service
usage information:
Estimated annual volume of IVES requests:

(Please attach an explanation for a “No” response.)

www.publish.no.irs.gov

Form 13803 (Rev. 1-2013)

Form 13803
(Rev. January 2013)

Continuation Sheet for Application to Participate in the
Income Verification Express Service (IVES) Program

OMB Number:

12. Complete the following information for the responsible official. The responsible official is an individual with
responsibility for the operation and IVES users at the business location listed above. A principle listed above may also
be a responsible official.
Responsible official name (first, middle initial, last)

Title

Social Security Number (Required)

Home Street Address

Telephone Number

Date of Birth (mm/dd/yyyy) (Required)

City

13.

State

ZIP Code

E-mail Address

By marking this box, you agree to review Publication 4557, Safeguarding Taxpayer Data and abide by the
guidelines of the publication. In addition, you can only use taxpayer information that you receive via a
Form 4506-T or Form 4506T-EZ request for the purpose(s) the taxpayer/requestor intended. Failing to
complete this section will result in the application being rejected and returned.

Where to fax your application: Please fax your application to IVES Coordinator Fax Number (TBD). The IRS conducts
a suitability check on the applicant, and on all Principals and Responsible Officials listed on the application to determine
the applicant’s suitability to be an IVES participant. After an applicant passes the suitability check and the IRS completes
processing the application, the IRS notifies the applicant of acceptance to participate in the program.
A Responsible Company Official must sign the application agreement indicating understanding of the Privacy Act
restrictions relating to the use of this service.
Privacy Act Notice: Our right to ask for information is 5 U.S.C. 301 and the Internal Revenue Code Section 6109 and
applicable regulations. The registration information we are requesting is used to create an account for you, authenticate
your identity and for billing purposes. We may disclose the information to the Department of Justice, to enforce the tax
laws, civil and criminal, to cities, states, the District of Columbia and U.S. commonwealths or possessions to carry out
their tax laws. We may give it to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. Your participation in the
Income Verification Express Services (IVES) program is voluntary, however, if you do not provide all or part of the
information required to create your account, you will not be eligible for access to IVES.
Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information,
and to the best of my knowledge and belief, the information being provided is true, correct, and complete. In addition,
I have read the Internal Revenue Service rules and procedures for participating in the Income Verification Express
Service program and I agree to abide by them and to pay resulting fees timely. I understand that failure to do so will
result in a temporary or permanent exclusion from the program.

Name and title of Principal, Partner or Owner (type or print) Signature of Principal, Partner or Owner Date

Acceptance for participation is not transferable. I understand that if this business is sold or its organizational structure
changes, a new application must be filed. I further understand that noncompliance will result in the business and/or the
individuals listed on this application, being suspended from participation in the IVES Program.

Catalog Number 48547A

www.publish.no.irs.gov

Form 13803 (Rev. 1-2013)