Form 13775 Tax Check Waiver

Form

13775

(January 2015)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-1791

Tax Check Waiver

The purpose of this form is to permit the Internal Revenue Service (IRS) to release information about the applicant which would
otherwise be confidential. This information will be used in connection with my application for appointment to membership in one of the
IRS Advisory Committee/Council. This waiver is made pursuant to 26 U.S.C. 6103(c).
Name of applicant
Name of the IRS Advisory Committee/Council for which you are
applying or continuing in membership

Internal IRS USE ONLY: Completed by the IRS Advisory Committee/Council Program Manager
Name and title of the authorized official

You are required to answer all the following questions:

Check Only One Box

1. Have you failed to timely file a Federal income tax return by the required due date (determined
with regard to any extension(s) of time for filing) for any of the last three years for which filing of
a return was required?
(NOTE: If the filing date [without regard to extensions] and normal processing period for the
most recent year's return has not yet elapsed on the date IRS receives this waiver, and IRS
records do not indicate a return for the most recent year, the "last three years" will mean the
three years preceding the year for which returns are currently being filed and processed.)

Yes

No

2. Have you failed to pay any tax, penalty, or interest liability during the current or last three
calendar years within ten (10) days of the date on which the IRS gave notice of the amount due
and requested payment

Yes

No

3. Are you now or have you ever been under investigation for a misdemeanor or criminal offenses

Yes

No

4. Have any civil penalties for fraud been assessed against you during the current or last three
calendar years

Yes

No

Comments (If you answered "Yes" to question 1, 2, 3, or 4, provide your explanation below. You may also use this space to address
any other tax compliance issue you believe is pertinent to this application.)

Provide the names and addresses shown on your last three tax returns (if different from the information provided in the Applicant
Address and Signature section on page two).
Year
1.

20

2.

20

3.

20

Name(s)

Catalog Number 48048G

Address

www.irs.gov

Form 13775 (Rev. 1-2015)

Page 2

Applicant Address and Signature
I request and authorize the IRS' Office of Governmental Liaison and Disclosure to release tax return and any relevant information necessary to respond
to the questions on page one to the appropriate IRS officials. To help the IRS find my tax records, I am voluntarily giving the following information (type
or print your information).

Applicant name

Applicant Social Security Number

Home address
City

State

ZIP code

Home telephone number (include area code)

Business/Work telephone number (include area code)

Applicant signature

Date signed

(Signature of the applicant authorizing the disclosure of
confidential tax information.)

(This consent is valid only if received by the IRS within 120 days of
this date.)

If married and filing a Joint Return (Spouse must complete the following information)
Spouse's name

Spouse's Social Security Number

Spouse's signature

Date signed

(If married and filing a Joint Return - Spouse's Signature is required.)

(This consent is valid only if received by the IRS within 120 days of
this date.)

Privacy Act Statement
The Privacy Act of 1974 requires that when we ask you 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 you for the information is 5 U.S.C. 301 and Executive Order (E.O.) 9397. We are asking for this information to determine your suitability as an employee
(direct hire or contracted), consultant or advisor of the Internal Revenue Service.
If you do not provide us with this information, it may adversely affect our ability to consider you. Any adverse information will be shared with the appropriate IRS
office(s) and may be disclosed to other federal agencies as required by law. Requesting you Social Security Number, under authority 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.

Paperwork Reduction Act Notice
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 48048G

www.irs.gov

Form 13775 (Rev. 1-2015)