Application for Security Summit Membership

Form

15058

(March 2018)

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Department of the Treasury - Internal Revenue Service

Application for Security Summit Membership

OMB Number
1545-

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You may fax your application to: 855-811-8020
Or send by mail to:
Internal Revenue Service National Public Liaison
Room 7559 CL:NPL
1111 Constitution Ave, NW
Washington, DC 20224

Part I: Applicant Information
Agency/Organization name
Agency/Organization address
City

State

Business telephone number

ZIP code

Contact name

Address
City

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State

Email address

Telephone number

ZIP code

Job title

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Part II: Required Criteria and Qualifications
See the attached membership criteria document to determine the appropriate categorization which best aligns with your agency or
organization and submit a short (one to two page) statement (Statement of Interest) describing your agency’s or organization’s role,
mission and functional responsibilities within the tax ecosystem. Also indicate your expectation of the Security Summit including your
anticipated contribution and benefits expected. This application is to be signed by the Head of Agency/Senior Executive of the
respective Agency/Organization.
Select the membership category you are applying for:
State/City
Software Developer/Electronic Return Originator (ERO)
Financial Services
Payroll Reporting Agents
Endorsing Organization
Other

Part III: 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. I have
read, understand and attest that my agency/organization meets the criteria required for Security Summit membership. I agree to
immediately notify the designated IRS Official when adding or removing representatives from our agency/organization participating in
Security Summit activities.
Print name

Title

Signature

Date

Paperwork Reduction Act Notice - This information is solicited under authority of 5 U.S.C. 301, 26 U.S.C. 7801 and 26 U.S.C. 7803 . The primary purpose of this form
is to process applications for membership. Providing this information is voluntary . Not providing all or part of the information may affect the application process. 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. 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: 5 minutes.

Catalog Number 71285H

www.irs.gov

Form 15058 (3-2018)

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