Form 8569 Form 8569 Geographic Availability Statement

OMB No.
1545-0973

Geographic Availability Statement

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 Internal Revenue Code Section 6103.

Paperwork Reduction Act Notice: This form is used in considering applicants
for the Senior Executive Service Candidate Development Program and other
executive positions. Your response is voluntary; however, your failure to
provide this information could effect your consideration for this program. This
signed statement will remain the minimum area of availability and will be used
for future job placement consideration. Employees must secure the approval of
the Executives Resources Board for any change in their area of availability.
Based upon your experience and prior assignments, you will be considered for
any Board covered position located in the area of your geographic availability.
The cities listed below are not all inclusive but are intended to provide you with
a general idea of where IRS offices do or may exist.

The time needed to complete the geographic availability statement is twenty
minutes. If you have comments concerning the accuracy of this time estimate
or suggestions for making this form simpler, we would be happy to hear from
you. You can write to Internal Revenue Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6406,
Washington, DC 20224. DO NOT send the completed Geographic Availability
Statement to this office.

Availability for Headquarter Operations in Washington, DC and/or Atlanta is required.
I am available for all locations.
I am available for only those locations marked below. (You must mark all locations for which you are
available. If you are only available for Washington, DC and/or Atlanta, you must mark which one or both.)
Atlanta GA

Fresno CA

Memphis TN

Andover MA

Ft. Lauderdale FL

Nashville TN

Austin TX

Greensboro NC

Newark NJ

Baltimore MD

Hartford CT

New Orleans LA

Boston MA

Houston TX

Oakland CA

Brookhaven NY

Indianapolis IN

Ogden UT

Brooklyn NY

Jacksonville FL

Philadelphia PA

Chicago IL

Kansas City MO

Phoenix AZ

Cincinnati OH

Laguna Niguel CA

San Francisco CA

Dallas TX

Los Angeles CA

Seattle WA

Denver CO

Manhattan NY

St. Louis MO

Detroit MI

Martinsburg WV

St. Paul MN
Washington DC Metropolitan Area

Remarks

Name (Please type)
Signature
Return completed form to

Form 8569 (Rev. 4-2006)

Date signed
Internal Revenue Service
Attn: Executive Services Division
OS:HC:S Room 3511
1111 Constitution Ave., NW
Washington, DC 20224
Catalog Number 63618S

www.irs.gov

Department of the Treasury-Internal Revenue Service