Form 13768 Electronic Tax Administration Advisory Committee Members

Form

13768

(March 2018)

Department of the Treasury - Internal Revenue Service

Electronic Tax Administration Advisory Committee
Membership Application

Complete this application and return it to the address below by Thursday,

OMB Number
1545-2231

May 10, 2018.

You may also fax your application to: 855-811-8020.
Internal Revenue Service National Public Liaison
Attn: ETAAC Program Manager (Room 7559) CL:NPL
1111 Constitution Ave, NW
Washington, DC 20224
Part I - Applicant Information (Some of the information requested in Part I is required to perform an FBI background check)
Name

Maiden name/other name(s) used

Home address

Home telephone number

City

State

Date of birth (mm-dd-yyyy)

Date(s) name(s) were used

City of birth

ZIP code
State of birth

Business name
Business address
City

Job title
State

Business telephone number

Business FAX number

ZIP code
Email address

Part II - Applicant must complete and submit Form 13775, Tax Check Waiver, with this form
Part III - Desired Skills and Qualifications (Complete the remainder of this section)
Submit a brief statement addressing your past or current affiliations and dealings with a particular organization or group
that you represent and how such dealings will allow you to know the view's or position of that particular organization or
group. In addition, submit a short (one or two page) statement, including recent examples, addressing your specific skills,
experience, and qualifications as they relate to the following:
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Experience in cybersecurity and information security
Experience in tax software development
Experience in tax preparation
Experience in payroll and tax financial product processes
Experience in systems management and improvement
Experience in implementation of customer service initiatives
Experience in consumer advocacy and public administration
Ability to examine issues from a macro viewpoint, and effectively communicate recommendations

Part IV - Applicant Resume
Attach a copy of your resume, to include prior Treasury and/or IRS employment, state position(s), title(s), and dates of
employment. In addition, list professional credentials, membership in professional organizations, and local liaison activities
with IRS, if applicable.

Catalog Number 47884W

www.irs.gov

Form 13768 (Rev. 3-2018)

Page 2

Part V - Prior IRS Councils/Committees
Have you ever been a member of the Internal Revenue Service Advisory Council, (formerly known as the Commissioner's
Advisory Group), Art Advisory Panel, Electronic Tax Administration Advisory Committee, Tax Exempt Advisory
Committee, Taxpayer Advocacy Panel, or Information Reporting Program Advisory Committee? If so, please include the
name of the councils/committees and dates of membership.
Council/Committee Name

Dates of Membership

Part VI - Applicant Signature
I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete and made in good
faith.
Signature

Date signed

Privacy Act and Paperwork Reduction Act Notice
The Privacy Act of 1974 requires that when we ask you for 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 for the information is Public Law 92-463 and Executive Order (E.O.) 9397. We are asking for the information
in order to perform Federal income tax, FBI, and practitioner checks as required of all members and applicants to the Electronic Tax Administration
Advisory Committee (ETAAC).
Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership in the ETAAC.
Requesting your social security number, which is solicited under authority of 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. However, not providing all or any part of the information may limit consideration of your application.
We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to give us the information. We need
it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of tax. 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 section 6103.The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average time is shown below. The estimated burden for all other taxpayers who file this form is
approved under OMB control number 1545-2231.
Preparing, copying, assembling, and sending the form to the IRS …………………….. 1 hour., 30 mins.
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from
you. You can write to: Internal Revenue Service, 1111 Constitution, Ave, NW, Washington, DC 20224. Do not send the form to this address. Instead
see the return address on the form.

Catalog Number 47884W

www.irs.gov

Form 13768 (Rev. 3-2018)