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Form 8453-EX Excise Tax Declaration for an IRS e-file Return
For the period beginning , 20 , and ending , 20
(Rev. December 2011) . OMB No. 1545-2082
Department of the Treasury For use with Forms 720, 2290, and 8849.
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Internal Revenue Service File electronically. Do not file paper copies. ▶ See instructions.
Name (as shown on Form 720, 2290, or 8849) Taxpayer identification number
Part I Type of Return and Return Information (Whole dollars only)
Check the box for the return for which you are using this Form 8453-EX and enter the applicable amount from the return. If you check
the box on lines 1a, 2a, or 3a, below, and the amount on that line for the return for which you are filing this form was blank, leave lines
1b, 1c, 2b, or 3b, whichever is applicable, blank (do not enter -0-). However, if you entered -0- on the return, enter -0- on the
applicable line below. Do not complete more than one line in Part I.
1a Form 720 check here ▶ b Balance due, if any (Form 720, Part III, line 10) . . . . . 1b
c Overpayment, if any (Form 720, Part III, line 11) . . . . 1c
2a Form 2290 check here ▶ b Balance due (Form 2290, line 6) . . . . . . . . . 2b
3a Form 8849 check here ▶ b Total refund (from Schedules 1, 2, 3, 5, 6, or 8) . . . . 3b
Caution. For line 3b, Schedules 2, 3, 5, and 8 cannot be combined with any other schedules. File a separate Form 8453-EX for each
schedule.
Part II Declaration of Taxpayer (see instructions)
4a I am requesting a refund on Form 720 or Form 8849.
b I authorize the U.S. Treasury and its designated Financial Agent to initiate an electronic funds withdrawal (direct debit) entry
to the financial institution account indicated in the tax preparation software for payment of the federal taxes owed for the
return indicated on lines 1a or 2a, and the financial institution to debit the entry to this account. To revoke a payment, I must
contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than two business days prior to the payment
(settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to
receive confidential information necessary to answer inquiries and resolve issues related to the payment.
Under penalties of perjury, I declare that the information I have given my electronic return originator (ERO), transmitter, and/or intermediate service provider (ISP) and the
amounts in Part I above agree with the amounts on the corresponding return. To the best of my knowledge and belief, the return is true, correct, and complete. I consent to
my ERO, transmitter, and/or ISP sending the return, this declaration, and accompanying schedules and statements to the IRS. I also consent to the IRS sending my ERO,
transmitter, and/or ISP an acknowledgment of receipt of transmission and an indication of whether or not the return is accepted and, if rejected, the reason(s) for the
rejection. If the processing of the return or refund is delayed, I authorize the IRS to disclose to my ERO, transmitter, and/or ISP the reason(s) for the delay, when the refund
was sent.
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Sign
Here Taxpayer’s signature Date
Part III Declaration of Electronic Return Originator (ERO) and Paid Preparer (see instructions)
I declare that I have reviewed the return indicated above and that the entries on Form 8453-EX are complete and correct to the best of my knowledge. If I am only a
collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the return. The taxpayer will have signed this form
before I submit the return. I will give the taxpayer a copy of all forms and information to be filed with the IRS, and have followed all other requirements in Pub. 3112, IRS
e-file Application and Participation, and Pub. 4163, Modernized e-File (MeF) Information for Authorized IRS e-file Providers for Business Returns. If I am also the paid
preparer, under penalties of perjury I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. This paid preparer declaration is based on all information of which I have any knowledge.
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Date Check if Check if self- ERO’s SSN or PTIN
ERO’s ERO’s also paid employed
signature ▲ preparer
Use Firm’s name (or yours EIN
Only if self-employed),
address, and ZIP code Phone no.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is
true, correct, and complete. This declaration is based on all information of which I have any knowledge.
Print/Type preparer’s name Preparer’s signature Date
Paid Check if PTIN
self-employed
Preparer ▶ Firm's EIN ▶
Firm’s name
Firm’s address
Use Only ▶ Phone no.
For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 49631B Form 8453-EX (Rev. 12-2011)
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