Form 12339 Internal Revenue Service Advisory Council Membership App

Form

12339

(May 2021)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-1791

Internal Revenue Service Advisory Council
Membership Application

Complete this application and submit it no later than Close of Business on July
You may also FAX your application to: 855-811-8021.

9, 2021, to [email protected].

PART I – Applicant Information (Some of the information requested in Part I is required to perform an FBI background check)
Name

Maiden name or other name(s) used

Date(s) names were used

Home street address

Home telephone number

City

State

Date of birth (mm-dd-yyyy)

City of birth

ZIP Code
State of birth

Business name
Business address

Job title

City

State

Business telephone number

Business FAX number

ZIP Code
Email address

Which of the following best describes your area of focus (check one box)
Large Business & International taxpayers
Small Business/Self-Employed taxpayers
Tax Exempt & Government Entities

Individual taxpayers

Information Reporting
PART II – Desired Skills and Qualifications

Submit a short (one or two page) statement, including recent examples, addressing how your skills and qualifications relate
to any of the following:
● Experience applying tax law knowledge in the resolution of complex tax issues
● Experience examining issues from a macro viewpoint and effectively communicating recommendations
● Experience working with third-party individuals or organizations who interact with the IRS on behalf of taxpayers
● Experience working in a multi-cultural/multi-lingual environment
● Experience in online services for tax professionals and user experience design

PART III – Applicant Resume
Attach a copy of your resume, including 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 28320P

www.irs.gov

Form 12339 (Rev. 5-2021)

PART IV – Previous IRS Council/Committee Membership
Have you ever been a member of the Internal Revenue Service Advisory Council (formerly known as Commissioner's Advisory Group),
Art Advisory Panel, Electronic Tax Administration Advisory Committee, Taxpayer Advocacy Panel, Advisory Committee on Tax Exempt
and Government Entities or Information Reporting Program Advisory Committee? If so, include name of the council/committee and
dates of membership.

Council/Committee Name

Dates of Membership

PART V – Consent to Disclose Tax Compliance Check
Upon submitting Form 12339 to the IRS, the applicant will receive via email Form 14767, Consent to Disclose Tax Compliance Check.
The applicant must submit Form 14767 in order to complete the application process.
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.
Applicant 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 Internal Revenue Service Advisory
Council.
Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership in the IRS
Advisory Council/Committee. 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 1545-1791.
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 28320P

www.irs.gov

Form 12339 (Rev. 5-2021)