Name: ________________________________________________
OCC Application Number: __________________________
TAX CHECK WAIVER
I am signing this waiver to permit the Internal Revenue Service (IRS) to release information about me which would otherwise be confidential. This waiver is made pursuant to 26 USC 6103(c).
I designate that the Internal Revenue Service release return and return information to:
(Insert Name)
(Insert Title)
Office of the Comptroller of the Currency
(Insert Address)
Check One:
|
□ Yes |
□ No |
|
□ Yes |
□ No |
3. Am I now or have I ever been under investigation for a misdemeanor or possible criminal offenses?
|
□ Yes |
□ No |
4. Has any civil penalty for fraud been assessed against me during the current or last three calendar years?
|
□ Yes |
□ No |
|
To help the IRS find my tax records, I am voluntarily giving the following information:
|
Name
(print or type):
Social
Security Number (SSN):
Current Home Address: _________________________________________________
_______________________________________________________________________
Telephone
Numbers: (Home)
(Work)
(Area Code) (Area Code)
Names and addresses shown on last three years’ returns (if different from above).
Year Name Address
I authorize the IRS to release any additional relevant information necessary to respond to the questions above.
Signature: _________ Date: _________________________
(Signature of taxpayer authorizing the disclosure of (This consent is valid only if received by the
Confidential tax information) IRS within 120 days of this date.)
Original signed signature and signed date is required
If married and filing a joint return:
Spouse’s
Name Spouse
SSN:
Signature: _________ Date: _________________________
(Signature of taxpayer authorizing the disclosure of (This consent is valid only if received by the
Confidential tax information) IRS within 120 days of this date.)
Original signed signature and signed date is required
Your social security number (and that of your spouse when joint returns have been filed) is requested to allow the Comptroller of the Currency to determine whether your Federal tax obligations have been fulfilled as part of its consideration of your suitability for a position as shareholder, officer, director, employee, or agent of a national bank or a Federal branch or agency. This information may be disclosed to other persons or governmental authorities.
Our authority for requesting this information is 12 U.S.C. § 1 et seq. and Executive Order 9397. Your provision of this information is voluntary. However, if you do not provide us with this information, it may adversely affect our ability to consider you.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2023-09-08 |