13551 Application to Participate in the IRS Acceptance Agent P

Form

For Official Use Only

Department of the Treasury - Internal Revenue Service

13551

Application to Participate in the
IRS Acceptance Agent Program

(Rev. August 2014)

Control number

OMB Number 1545-1896

(Read the instructions carefully before completing this Form)
Check the type of acceptance agent for
which you are applying:

Application Type:

If you are amending your application, select the reason below:

New
Renewal
Amended

Acceptance Agent
Certifying Acceptance Agent

Authorized Representative
Acceptance Agent Type
Other

1. Check the box that best describes Organization status

Business Location

Professional Status of Authorized Representative (Individual
Listed on Line 5)

Financial Institution
Corporation
Educational Institution
LLC
Casino
Sole Proprietorship
Partnership
Other
Government Agency or Military Organization

Tax Preparer
CPA*
ERO
Enrolled Agent* (Enter number)
Other
*See instructions for proof requirements

Attorney*
(Specify)

3. Business Electronic Filing Identification Number (EFIN)

2. Legal Name of Business (If an entity, also enter location where organized or created)

4. Business Employer Identification Number (EIN)

and Name and PTIN of Principal Partner or Owner of the Business (See Instructions)
5. Name and PTIN of Authorized Representative of the Business
(first, middle, last, PTIN)

6. Date of birth
(month, day, year)

7. Social Security Number (SSN) or Individual Taxpayer
Identification Number (ITIN)

8. Home address (street, city/county, state/country, and ZIP code/
foreign postal code) of individual listed on Line 5

9. Check the appropriate box 10. Have you ever been assessed any preparer penalties,
been convicted of a crime, failed to file personal tax
U.S. Citizen
returns, or pay tax liabilities, or been convicted of any
U.S. Resident Alien*
criminal offense under the U.S. Internal Revenue laws

Nonresident Alien*

Yes

*Attach copy of green card
or visa if residing in the U.S.

No

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

11. 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)
12. Business location address*

Street

City/County

State/Country

ZIP Code/Foreign Postal Code

*If more than one location, attach continuation sheets for each location and authorized representative(s) with required information.
13. Business telephone number

(

Fax number

)

(

)

Email

14. Mailing address of the Business if different from the location address on line 12
Number and street

City/County

15. Does the Business provide tax related services year round

Yes

State/Country
No

ZIP Code/Foreign Postal Code

If “No,” provide a brief explanation why.

15a. How many Form W-7 applications does the Business plan to submit within a 12-month calendar period
16. Complete the following information for Primary Contact if different than the authorized representative on Line 5 (see instructions)
Primary Contact name (first, middle initial, last)

Title

Email address

Phone number

(

)

Fax number

(

)

(

)

17. Complete the following information for Alternate Contact if different than the individual listed on Line 5 (see instructions)
Alternate Contact name (first, middle initial, last)

Title

Email address

Phone number

(

)

Fax number

18. Identify the activities performed by you or your organization (tax preparation, University, etc.) as well as the type of customers that you will service (foreign
investors, foreign students, etc.) to validate your request for Acceptance Agent status (see instructions)
19. If you would like to be included on the published list of Acceptance Agents located on the IRS website, check here.
Note: the business must perform tax preparation to be included on the list.
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. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our
participation. Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance
will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the
institution.

20. Name and title of Authorized Representative from line 5 (type or print)

21. Signature of Authorized Representative

22. Date

Name and title of Principal, Partner or Owner from line 2 (type or print)

Signature of Principal, Partner or Owner

Date

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your response is voluntary. You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue
law. Generally, tax returns and return information are confidential, as required by code section 6103. The estimated average time to complete this form is 30 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for
making this form simpler, we will be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224. Do NOT send this form to this
address. Instead, enclose it with the magnetic tape and send it to the Service Center to which you submit your tapes or send it to the transmission reception site that received your transmitted returns.

Catalog Number 38262Q

www.irs.gov

Form 13551 (Rev. 8-2014)

Page 2

Instructions for Form 13551, Application to Participate in the IRS Acceptance Agent Program
General Instructions
Purpose of this Form. All persons who wish to participate in the TIN (Taxpayer Identification
Number) Acceptance Agent Program must apply by completing this application.
What is an Acceptance Agent/Certifying Acceptance Agent. Acceptance agents are individuals
or entities (colleges, financial institutions, accounting firms, etc.) that have entered into formal
agreements with the IRS that permit them to assist alien individuals and other foreign persons with
obtaining TINs. The type of duties that you are permitted to perform is based upon your application
to become an acceptance agent or a certifying acceptance agent. (See Revenue Procedure 2006-10
for additional information.)
Who May Apply. Persons eligible to become acceptance agents include a financial institution
defined in section 265(b)(5) of the Internal Revenue Code (Code) or §1.165-12(c)(1)(iv) of the
regulations, a college or university that is an educational organization defined in §1.501(c)(3)-1(d)(3)
(i), a federal agency defined in section 6402(g) of the Code, persons that provide assistance to
taxpayers in the preparation of their tax returns, and any other person or categories of persons that
may be authorized by regulations or IRS procedures. An eligible person may be a U.S. person or a
foreign person. Each individual listed as a Principal, Partner or Owner of the business, authorized
representative or primary/ alternate contact of the business must have attained the age of 18 as of
the date of this application. A person required to become a Certified Acceptance Agent (CAA) must
be covered under the professional standards of Circular 230. This includes individuals who are
attorneys admitted to practice before the bar, Certified Public Accountants (CPAs), enrolled agents
and registered tax return preparers not under suspension or disbarment from practice before IRS.
When to Apply. All new and renewal applications will only be accepted during the program’s “open
season” which is May 1 through August 31 each year. Therefore, if your AA Agreement is due to
expire during the current year, it is important to submit a new application during the open season so
that the operations of your business are not interrupted. It can take up to four months from the time
that you submit your application to receive your approved Acceptance Agent Agreement from IRS.
How to Apply. All new and renewing persons will be required to complete Form 13551 (Application
to Participate in the IRS Acceptance Agent Program). In addition, there must be an attached
fingerprint card or proof of professional status for each individual listed on Line 5 as an Authorized
Representative (see instructions for fingerprint cards below.) Prior to applying for Acceptance Agent
Status, mandatory training must be completed and the self-certification at the end of the training
must be signed and attached to your Form 13551 when submitting it to IRS. The training is available
online at www.IRS.gov. and can be accessed by entering “How to become an Acceptance Agent” in
the search feature in the upper right corner of the IRS home page. Forensic training documentation
for new and renewal applications must also be attached to Form 13551. Note: Your application to
become an Acceptance Agent will not be processed without an attached, signed, self-certification
training and documentation of forensic training.
Fingerprint Cards. Each individual listed as a responsible party or authorized representative of the
business must have attained the age of 18 as of the date of this application. If the authorized
representative is an attorney, CPA or enrolled agent, but not a certified Electronic Return Originator
(ERO), evidence of U.S. professional status may be submitted in lieu of the fingerprint card. The
following persons are exempt from the fingerprinting requirement: a financial institution within the
meaning of I.R.C. 265(b)(5) or Treasury Regulations 1.1 65-1 2(c)(1)(iv), a college or university that
qualifies as an educational organization under Treasury Regulations 1.501 (c)(3)-l (d)(3)(i), a casino,
Federal agencies as defined in IRC 6402(g) an ERO in good standing with the IRS and foreign
nationals without a Social Security Number (SSN) residing outside the United States. (Evidence of
your professional status may be obtained by contacting the issuing authority.)
Note: Individuals CANNOT take their own fingerprints. The fingerprint card used for the Acceptance
Agent Program is unique, and should be obtained by calling the IRS Austin Campus at
1-866-255-0654. If the authorized representative of the business changes, the business must
submit an amended application, including a new fingerprint card, if required, for the authorized
representative. Your application will not be processed if you do not provide a completed fingerprint
card or evidence of professional status and the original signature of both the authorized
representative and the principal, partner or owner or owner of the business. Faxed copies of this
application will not be accepted.
When to Update Information. Acceptance Agents must notify the IRS within 30 days of all changes
to the information they originally submitted on Form 13551, Application to Participate in the IRS
Acceptance Agent (AA) Program, by completing another Form 13551 and checking the “amended”
box and attach a statement explaining the changes. This is important for several reasons. If
information is not up-to-date on our database, you may not receive important IRS information or
correspondence. Be sure to fully complete the application changing only the information that is
different from that submitted on the original Form 13551. The revised Form 13551 will not change
your address of record for tax purposes, nor will it automatically update information associated with
your EIN (Employer’s Identification Number).
Where to Apply. Send Form 13551, along with your completed fingerprint card or evidence of
professional status if required, forensic documentation, and mandatory training certification to:
Internal Revenue Service
3651 S. IH 35
Stop 6380AUSC
Austin, TX 78741
Note: Be sure that your application has been fully completed and contains the signature of the
authorized representative and principal, partner or owner of the original business. (See instructions
for Line 20.)
Who to Contact for Assistance. If you need additional assistance in completing this application
you can email the ITIN Policy Section at [email protected] where someone will respond to
you. For additional information about Acceptance Agents, refer to Revenue Procedure 2006-10. For
additional information about the Form W-7, see Publication 1915 Understanding Your Individual
Taxpayer Identification Number - ITIN.
How To Complete The Form Check the applicable box to indicate if you are (1) a NEW applicant, (i.
e. the first time that the Business is applying for Acceptance Agent/Certifying Acceptance Agent
status), (2) seeking Renewal of a AA/CAA Agreement that will be expiring or (3) Amending
information on a Business that is already an AA/CAA (i.e. submitting an application for a new
authorized representative; changing primary or alternate contacts, etc.) See Revenue Procedure
2006-10 for additional information on Acceptance Agents. For additional information on submitting
an amended application, see “When to Update Information” above.
Line 1. Check the box which best describes the organizational status of the business. If the “Other”
box is checked, please insert a brief explanation that best describes the organizational status. Also
check the box that best describes the professional status of the applicant. CPAs, Attorneys and
Enrolled Agents must attach a copy of an unexpired credential. For example, a valid CPA license, a

Catalog Number 38262Q

record from the state bar, or Enrolled Agent enrollment card. If the “Other” box is checked, please
insert a brief explanation that best describes the professional status. If you are applying for
Acceptance Agent status as a nonprofit organization, attach a copy of your IRS exemption letter.
Line 2. Enter the legal name of the business and the name of the principal, partner or owner of the
business along with their PTIN (Preparer Tax Identification Number) if one was issued. A PTIN must
be obtained by all enrolled agents, as well as all tax return preparers who are compensated for
preparing, or assisting in the preparation of, all or substantially all of any U.S. federal tax return. If
your firm is a sole proprietorship, enter the name of the sole proprietor. If the applicant is an entity,
provide the state, including the District of Columbia (or if outside the United States, the country
under whose laws the entity was created or organized). If submitting an amended application and
the legal name of the business is not changing, be sure this entry is identical to the one on your
original application. The Principal, Partner or Owner of the business is defined below: For entitles
with shares of interests traded on a public exchange, or which are registered with the Securities and
Exchange Commission, that individual is (a) the “principal” officer if the business is a corporation,
(b) a general “partner”, if a partnership, (c) the “owner” of an entity that is disregarded as separate
from its owner, or (d) a grantor, owner or trustor, if a trust. For all other entities, it is the person who
has a level of control over, or entitlement to, the funds or assets in the entity that, as a practical
matter, enables the individual, directly or indirectly, to control, manage or direct the entity and the
disposition of its funds and assets
Line 3. If the business is already an authorized IRS e-file provider, enter the EFIN (Electronic Filing
Identification Number). An authorized IRS e-file provider is a business (sole proprietorship,
partnership, corporation or other entity) that has been accepted into the IRS e-filing program and
has been assigned an electronic filing identification number. The EFIN must be the registered
number for the location specified and EIN.
Line 4. Enter the IRS issued Employer Identification Number (EIN). Note: All businesses must obtain
an EIN before submitting your application.
Line 5. Enter the name, title and PTIN of the authorized representative. This person will be the
official point of contact with the IRS and is responsible for ensuring that all requirements of the
Acceptance Agent program are followed. They are the only individuals, other than the principal,
partner or owner, who have authority to sign the Certificates of Accuracy. Each business location is
permitted to select up to ten authorized representatives. If you need extra space to add additional
authorized representatives for the business location listed on Page 1, or for additional business
locations, use the continuation sheet attached to the Form 13551.
Line 6. Enter the date of birth of the authorized representative of the business listed on Line 5. This
information should be entered in mm/dd/yyyy format (i.e. April 15, 1950, should be entered as
04/15/1950).
Line 7. Enter the Social Security Number or TIN of the authorized representative of the business. If
you are a foreign national living outside the U.S. and do not have an SSN or ITIN, please enter N/A.
Line 8. Enter the complete home address of the authorized representative of the business (street,
city/county, state/country and zip code/foreign postal code).
Line 9. Check the box which describes the legal status (in the U.S.) of the person entered on line 5.
Attach a copy of the green card or visa, if you are not a U.S. citizen but are residing in the U.S.
Line 10. If you answered “Yes” to the suitability question in box 10, please provide an explanation
including dates and circumstances and why you believe that it should not affect your fitness to be an
acceptance agent or certifying acceptance agent. You will also need to attach a fingerprint card with
your application.
Line 11. For the purpose of becoming an acceptance agent, if a “doing business as” (DBA) name is
used other than the name provided on Line 2, enter that information here and include a brief
explanation. Use an additional sheet of paper if you need more space. Note: The business will be
authorized to operate as an AA/CAA only under the name provided here or on Line 2.
Line 12. Enter the complete street address, city/county, state/country and zip code/foreign postal
code where the business is located. Note: A post office box (P.O. Box) will not be accepted as part
of the address.
Line 13. Enter the telephone number, fax number, and email address of the business. If, in addition
to the business telephone, there is another number where you would like to be contacted by IRS,
you may enter that information on this line also, notating that it is the alternative telephone number.
Line 14. This line should be completed only if you are using a business mailing address that is
different from the address entered on Line 12. The same mailing address can not be used for
multiple business locations.
Line 15. Check the “yes” or “no” box to indicate if the business provides tax related services year
round (January through December). If the answer is “no”, provide a brief explanation why the
business does not provide tax related services year round.
Line 15a. Enter the volume of Forms W-7 that you anticipate filing during a 12 month calendar
period.
Lines 16 and 17. Enter the name of the primary and alternate contact(s) only if different than the
authorized representative(s) of the business (individual listed on Line 5 or on the continuation sheet
(s) to the application). This is the person that has been authorized by the business to contact the
ITIN Operations to inquire about the status of W-7 applications, but they are not permitted to sign the
Form W-7(COA). Also provide the person’s business title, telephone and fax numbers and their
email address. Each business location may have one primary and one alternate contact.
Line 18. You may attach a separate statement to provide a detailed description of the activities
performed by the business which would validate this request for Acceptance Agent status. For
example, a tax preparation firm preparing U.S. federal income tax returns for nonresident alien real
estate investors who do not qualify for an SSN, would establish your purpose for applying for entry
into the AA Program.
Line 19. If the business performs tax return preparation, the principal, partner or owner of the
business may request to be included on a public list of acceptance agents published by the IRS on
its website.
Lines 20 and 21. Both the authorized representative and the principal, partner or owner must print
and sign their name to this application. By signing the application you are authorizing the Internal
Revenue Service to conduct suitability checks as referenced in the Revenue Procedure.
Line 22. Enter the date that this application is signed.
Pages 3 and 4 – (Continuation sheets)
Note: Must be attached to a Form 13551 when submitted to IRS. Use pages 3 and 4 to add
additional authorized representatives or a primary and alternate contact for a business location. If
the business operates at more than one location, use a separate continuation sheet for each
additional office. The continuation pages must also be signed and dated by the Principal, Partner or
Owner of the Business (signature space provided on page 4) and each additional authorized
representative, pursuant to the signature requirements for Form 13551, Lines 20 and 21.

www.irs.gov

Form 13551 (Rev. 8-2014)

Page 3

Form

13551

Department of the Treasury - Internal Revenue Service

OMB Number
1545-1896

Continuation Sheet for Additional Authorized Representatives

(Rev. August 2014)

(see Form 13551 instructions)
Business EFIN

Legal Name of the Business (Page 1, Line 2 (and 11, if applicable))

Business location address

Street

City/County

Business EIN

State/Country

ZIP Code/Foreign Postal Code

Information and Signature of Additional Authorized Representative
Professional Status of
Authorized
Representative (Line 5)
Tax Preparer
CPA*
Attorney*

5. Name and PTIN of Authorized Representative of
the Business (first, middle, last, PTIN)

6. Date of birth
(month, day, year)

8. Home address (street, city/county, state/country,
and ZIP code/foreign postal code) of individual
listed on Line 5

9. Check the appropriate box 10. Have you ever been assessed any preparer
penalties, been convicted of a crime, failed to
U.S. Citizen
file personal tax returns, or pay tax liabilities,
or been convicted of any criminal offense
U.S. Resident Alien*
under the U.S. Internal Revenue laws

Enrolled Agent*

7. Social Security Number (SSN) or Taxpayer
Identification Number (ITIN)

Nonresident Alien*

number

Yes

*Attach copy of green card
or visa if residing in the U.S.

Other

No

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

*See instructions for
proof requirements
13. Business telephone number
(

)

Fax number

14. Mailing address of the Business if different from the location address on line 12

(

Number and street

)

City/County

State/Country

ZIP Code/Foreign Postal Code

Email
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. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for
Acceptance Agents and related publications each year of our participation.
Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that
noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to
make and sign this statement on behalf of the institution.

Name and title of Authorized Representative from line 5 (type or print)

Signature of Authorized Representative

Date

Information and Signature of Additional Authorized Representative
Professional Status of
Authorized
Representative (Line 5)
Tax Preparer
CPA*
Attorney*

5. Name and PTIN of Authorized Representative of
the Business (first, middle, last, PTIN)

6. Date of birth
(month, day, year)

8. Home address (street, city/county, state/country,
and ZIP code/foreign postal code) of individual
listed on Line 5

9. Check the appropriate box 10. Have you ever been assessed any preparer
penalties, been convicted of a crime, failed to
U.S. Citizen
file personal tax returns, or pay tax liabilities,
or been convicted of any criminal offense
U.S. Resident Alien*
under the U.S. Internal Revenue laws

Enrolled Agent*

7. Social Security Number (SSN) or Taxpayer
Identification Number (ITIN)

Nonresident Alien*

number

Yes

*Attach copy of green card
or visa if residing in the U.S.

Other

No

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

*See instructions for
proof requirements
13. Business telephone number
(

)

Fax number

14. Mailing address of the Business if different from the location address on line 12

(

Number and street

)

City/County

State/Country

ZIP Code/Foreign Postal Code

Email
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. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for
Acceptance Agents and related publications each year of our participation.
Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that
noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to
make and sign this statement on behalf of the institution.

Name and title of Authorized Representative from line 5 (type or print)

Signature of Authorized Representative

Date

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your response is voluntary. You
are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records
relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return
information are confidential, as required by code section 6103. The estimated average time to complete this form is 30 minutes. If you have comments concerning the accuracy of this
time estimate or suggestions for making this form simpler, we will be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:
W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224. Do NOT send this form to this address. Instead, enclose it with the magnetic tape and send it to the Service
Center to which you submit your tapes or send it to the transmission reception site that received your transmitted returns.

Catalog Number 38262Q

www.irs.gov

Form 13551 (Rev. 8-2014)

Page 4

Information and Signature of Additional Authorized Representative
Professional Status of
Authorized
Representative (Line 5)
Tax Preparer
CPA*
Attorney*

5. Name and PTIN of Authorized Representative of
the Business (first, middle, last, PTIN)

6. Date of birth
(month, day, year)

8. Home address (street, city/county, state/country,
and ZIP code/foreign postal code) of individual
listed on Line 5

9. Check the appropriate box 10. Have you ever been assessed any preparer
penalties, been convicted of a crime, failed to
U.S. Citizen
file personal tax returns, or pay tax liabilities,
or been convicted of any criminal offense
U.S. Resident Alien*
under the U.S. Internal Revenue laws

Enrolled Agent*

7. Social Security Number (SSN) or Taxpayer
Identification Number (ITIN)

Nonresident Alien*

number

Yes

*Attach copy of green card
or visa if residing in the U.S.

Other

No

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

*See instructions for
proof requirements
13. Business telephone number
(

)

Fax number

14. Mailing address of the Business if different from the location address on line 12

(

Number and street

)

City/County

State/Country

ZIP Code/Foreign Postal Code

Email
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. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for
Acceptance Agents and related publications each year of our participation.
Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that
noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to
make and sign this statement on behalf of the institution.

Name and title of Authorized Representative from line 5 (type or print)

Signature of Authorized Representative

Date

Information and Signature of Additional Authorized Representative
Professional Status of
Authorized
Representative (Line 5)
Tax Preparer
CPA*
Attorney*

5. Name and PTIN of Authorized Representative of
the Business (first, middle, last, PTIN)

6. Date of birth
(month, day, year)

8. Home address (street, city/county, state/country,
and ZIP code/foreign postal code) of individual
listed on Line 5

9. Check the appropriate box 10. Have you ever been assessed any preparer
penalties, been convicted of a crime, failed to
U.S. Citizen
file personal tax returns, or pay tax liabilities,
or been convicted of any criminal offense
U.S. Resident Alien*
under the U.S. Internal Revenue laws

Enrolled Agent*

7. Social Security Number (SSN) or Taxpayer
Identification Number (ITIN)

Nonresident Alien*

number

Yes

*Attach copy of green card
or visa if residing in the U.S.

Other

No

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

*See instructions for
proof requirements
13. Business telephone number
(

)

Fax number

14. Mailing address of the Business if different from the location address on line 12

(

Number and street

)

City/County

State/Country

ZIP Code/Foreign Postal Code

Email
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. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for
Acceptance Agents and related publications each year of our participation.
Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that
noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to
make and sign this statement on behalf of the institution.

Name and title of Authorized Representative from line 5 (type or print)

Signature of Authorized Representative

Date

Names and Contact Information for Primary and Alternate Contacts at the business location listed above. (Complete only if primary and alternate
contacts for this business location are not already listed as the primary and alternate contacts on page 1, line 16 of the attached Form 13551.
16. Complete information for primary contact if not listed on attached Form 13551
Name (first, middle initial, last) and Title

Complete information for alternate contact if not listed on attached Form 13551
Name (first, middle initial, last) and Title

Phone number (

Phone number (

)

Fax number (

)

Email

)

Fax number (

)

Email

Signature of Principal, Partner or Owner of Business
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. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our
participation.
Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance will result in the
institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the institution.

Name and title of Principal, Partner or Owner from line 2 (type or print)

Signature of Principal, Partner or Owner

Date

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Catalog Number 38262Q

www.irs.gov

Form 13551 (Rev. 8-2014)