Department of the Treasury - Internal Revenue Service For Official Use Only Form 13551 Application to Participate in the Control number (June 2019) IRS Acceptance Agent Program (Read the instructions carefully before completing this Form) OMB Number 1545-1896 Check the type of acceptance agent for Application Type If you are amending your application, select the reason below which you are applying New Authorized Representative Business Location Acceptance Agent (AA) Renewal Acceptance Agent Type Certifying Acceptance Agent (CAA) Amended (attach signed explanation) Other 1. Check the box that best describes Organization status Professional Status of Authorized Representative (Individual Financial Institution Corporation Listed on Line 5) Educational Institution LLC Tax Preparer CPA* ERO Attorney* Casino Sole Proprietorship Enrolled Agent* (Enter number) Partnership Other Other (specify) Government Agency or Military Organization *See instructions for proof requirements 2. Legal Name of Business (If an entity, also enter location where organized or created) 3. Business Electronic Filing Identification Number (EFIN) and Name and PTIN of Principal Partner or Owner of the Business (See Instructions) 4. Business Employer Identification Number (EIN) (Required) 5. Name and PTIN of Authorized Representative of the Business 6. Date of birth 7. Social Security Number (SSN) or Individual Taxpayer (first, middle, last, PTIN) (month, day, year) Identification Number (ITIN) 8. Home address (street, city/county, state/country, and ZIP code/ 9. Check the appropriate box 10. Have you ever been assessed any preparer penalties, foreign postal code) of individual listed on Line 5 U.S. Citizen been convicted of a crime, failed to file personal tax returns, or pay tax liabilities, or been convicted of any U.S. Resident Alien* criminal offense under the U.S. Internal Revenue laws Nonresident Alien** Yes No *Attach copy of green card **Attach copy of visa if residing (Attach an explanation and fingerprint cards for a “Yes” in the U.S. response.) 11. Doing Business As (DBA) name (complete only if the business is operating under a name which is different than the business name listed on Line 2) 12. Business location address* Street City/County State/Country ZIP Code/Foreign Postal Code *If more than one location, attach continuation sheets for each location and authorized representative(s) with required information. 13. Business telephone number ( ) Fax number ( ) Email 14. Mailing address of the Business if different from the location address on line 12 Number and street City/County State/Country ZIP Code/Foreign Postal Code 15. Does the Business provide tax related services year round Yes No If “No,” provide a brief explanation why 15a. How many Form W-7 applications does the Business plan to submit within a 12-month calendar period 16. Complete the following information for Primary Contact if different than the authorized representative on Line 5 (see instructions) Primary Contact name (first, middle initial, last) Title Email address Phone number ( ) Fax number ( ) 17. Complete the following information for Alternate Contact if different than the individual listed on Line 5 (see instructions) Alternate Contact name (first, middle initial, last) Title Email address Phone number ( ) Fax number ( ) 18. Identify the activities performed by you or your organization (tax preparation, University, etc.) as well as the type of customers that you will service (foreign investors, foreign students, etc.) to validate your request for Acceptance Agent status (see instructions) 19. If you would like to be included on the published list of Acceptance Agents located on the IRS website, check here Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our participation. Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the institution. 20. Name and title of Authorized Representative from line 5 (type or print) 21. Signature of Authorized Representative 22. Date Name and title of Principal, Partner or Owner from line 2 (type or print) Signature of Principal, Partner or Owner Date Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your response is voluntary. 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 code section 6103. The estimated average time to complete this form is 30 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we will be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224. Do NOT send this form to this address. Instead, enclose it with the magnetic tape and send it to the Service Center to which you submit your tapes or send it to the transmission reception site that received your transmitted returns. Catalog Number 38262Q www.irs.gov Form 13551 (Rev. 6-2019) |
Page 2 Instructions for Form 13551, Application to Participate in the IRS Acceptance Agent Program General Instructions Line 1. Check the box which best describes the organizational status of the business. If the “Other” box Purpose of this Form. All persons who wish to participate in the TIN (Taxpayer Identification Number) is checked, please insert a brief explanation that best describes the organizational status. Also check Acceptance Agent Program must apply by completing this application. the box that best describes the professional status of the applicant. CPAs, Attorneys and Enrolled Agents must attach a copy of an unexpired credential. For example, a valid CPA license, a record from What is an Acceptance Agent/Certifying Acceptance Agent. Acceptance agents areindividuals or the state bar, or Enrolled Agent enrollment card. If the “Other” box is checked, please insert a brief entities (colleges, financial institutions, accounting firms, etc.) that have entered into formal agreements explanation that best describes the professional status. If you are applying for Acceptance Agent status with the IRS that permit them to assist alien individuals and other foreign persons with obtaining TINs. as a nonprofit organization, attach a copy of your IRS exemption letter. The type of duties that you are permitted to perform is based upon your application to become an Enter the legal name of the business and the name of the principal, partner or owner of the Acceptance Agent (AA) or a Certifying Acceptance Agent (CAA). (See Revenue Procedure 2006-10 for Line 2. additional information.) business along with their PTIN (Preparer Tax Identification Number) if one was issued. A PTIN must be obtained by all enrolled agents, as well as all tax return preparers who are compensated for preparing, Who May Apply. Persons eligible to become acceptance agents include a financial institution defined in or assisting in the preparation of, all or substantially all of any U.S. federal tax return. If your firm is a section 265(b)(5) of the Internal Revenue Code (Code) or §1.165-12(c)(1)(iv) of the regulations, a sole proprietorship, enter the name of the sole proprietor. If the applicant is an entity, provide the state, college or university that is an educational organization defined in §1.501(c)(3)-1(d)(3)(i), a federal including the District of Columbia (or if outside the United States, the country under whose laws the agency defined in section 6402(h) of the Code, state and local governments, including agencies entity was created or organized). If submitting an amended application and the legal name of the responsible for vital records, community-based organizations defined in section 501(c)(3) or (d) of the business is not changing, be sure this entry is identical to the one on your original application. The Code, persons that provide assistance to taxpayers in the preparation of their tax returns, and any other Principal, Partner or Owner of the business is defined below: For entitles with shares of interests traded person or categories of persons that may be authorized by regulations or IRS procedures. An eligible on a public exchange, or which are registered with the Securities and Exchange Commission, that person may be a U.S. person or a foreign person. Each individual listed as a Principal, Partner or individual is (a) the “principal” officer if the business is a corporation, (b) a general “partner”, if a Owner of the business,authorized representative or primary/ alternate contact of the business must partnership, (c) the “owner” of an entity that is disregarded as separate from its owner, or (d) a grantor, have attained the age of 18 as of the date of this application. owner or trustor, if a trust. For all other entities, it is the person who has a level of control over, or When to Apply. New and renewal applications may be submitted year-round. However, to prevent entitlement to, the funds or assets in the entity that, as a practical matter, enables the individual, interruption of your business operations, a renewal application should be submitted at least six months directly or indirectly, to control, manage or direct the entity and the disposition of its funds and assets before the expiration date of your Agreement. It can take up to 120 days (four months) from the time Line 3. If the business is already an authorized IRS e-file provider, enter the EFIN (Electronic Filing that you submit your application to receive your approved Acceptance Agent Agreement from IRS. Identification Number). An authorized IRS e-file provider is a business (sole proprietorship, partnership, How to Apply.All new and renewing persons will be required to complete Form 13551(Application to corporation or other entity) that has been accepted into the IRS e-filing program and has been assigned Participate in the IRS Acceptance Agent Program). In addition, there must be an attached fingerprint an electronic filing identification number.The EFIN must be the registered number for the location card or proof of professional status for each individual listed on Line 5 as an Authorized Representative specified and EIN. (see instructions for fingerprint cards below.) Prior to applying for Acceptance Agent Status, mandatory Line 4. Enter the IRS issued Employer Identification Number (EIN). Note: All applicants must obtain an Acceptance Agent training must be completed and the certificate at the end of the training must be EIN before submitting this application. signed and attached to your Form 13551 when submitting it to IRS. To be valid, the mandatory training Enter the name, title and PTIN of the authorized representative. This person will be the official certificate must be dated within 120 days of the date entered on Line 22. The training is available online Line 5. at www.IRS.gov/itinagents. Original forensic document training certificates for new and renewal point of contact with the IRS and is responsible for ensuring that all requirements of the Acceptance applications submitted by CAAs must also be attached. Note: Your application to become a CAA will Agent program are followed. They are the only individuals, other than the principal, partner or owner (if not be processed if you do not attach a signed mandatory Acceptance Agent training certificate. If also listed as an authorized representative), who have authority to sign the Certificates of Accuracy. applying as a CAA, you must also attach an original forensic document training certificate for each Each business location is permitted to select up to ten authorized representatives. If you need extra Authorized Representative. space to add additional authorized representativesfor the business location listed on Page 1, or for additional business locations, use the continuation sheet attached to the Form 13551. Fingerprint Cards. Each individual listed as a responsible party or authorized representative of the business must be age 18 or older as of the date of this application. If the authorized representative is an Line 6. Enter the date of birth of the authorized representative of the business listed on Line 5. This Electronic Return Originator (ERO), fingerprint cards are not required. The authorized representative information should be entered in mm/dd/yyyy format (i.e. April 15, 1950, should be entered as must be listed as a Responsible Official on the EFIN to be exempt from the fingerprint requirement. If 04/15/1950). the authorized representative is an attorney, CPA or enrolled agent, but not an ERO, evidence of U.S. Line 7. Enter the Social Security Number or TIN of the authorized representative of the business. If you professional status may be submitted instead of the fingerprint card. If an ERO, include your EFIN on are a foreign national living outside the U.S. and do not have an SSNor ITIN, please enter N/A. Line 3. The following organizations are exempt from the fingerprinting requirement: a financial institution Line 8. Enter the complete home address of the authorized representative of the business (street, city/ within the meaning of I.R.C. 265(b)(5) or Treasury Regulations 1.1 65-1 2(c)(1)(iv), a college or county, state/country and zip code/foreign postal code). university that qualifies as an educational organization under Treasury Regulations 1.501 (c)(3)-l (d)(3) (i), a casino, Federal agencies as defined in IRC 6402(g) an ERO in good standing with the IRS and Line 9. Check the box which describes the legal status (in the U.S.) of the person entered on line 5. foreign nationals without a Social Security Number (SSN) residing outside the United States. (Evidence Attach a copy of the green card or visa, if you are not a U.S. citizen but are residing in the U.S. of your professional status may be obtained by contacting the issuing authority.) Line 10. If you answered “Yes” to the suitability question in box 10, please provide an explanation Note: Individuals CANNOT take their own fingerprints.The fingerprint card used for the Acceptance including dates and circumstances and why you believe that it should not affect your fitness to be an Agent Program is unique, and should be obtained by calling the IRS Austin Campus at 1-866-255-0654. AA/CAA. You will also need to attach fingerprint cards with your application. If the authorized representative of the business changes, the business must submit an amended Line 11. For the purpose of becoming an acceptance agent, if a “doing business as” (DBA) name is application, including a new fingerprint card, if required, for the authorized representative. Your used otherthan the name provided on Line 2, enter that information here and include a brief application will not be processed if you do not provide a completed fingerprint card or evidence of explanation. Use an additional sheet of paper if you need more space. Note: The business will be professional status and the original signature of both the authorized representative and the principal, authorized to operate as an AA/CAA only under the name provided here or on Line 2. partner or owner or owner of the business. Faxed copies or photocopies of this application will not be Line 12. Enter the complete street address, city/county, state/country and zip code/foreign postal code accepted. where the business is located. Note: A post office box (P.O.Box) will not be accepted as part of the When to Update Information. Acceptance Agents must notify the IRS within 30 days of all changes to address. the information they originally submitted on this application, by completing another Form 13551, Line 13. Enter the telephone number, fax number, and email address of the business. If, in addition to checking the “amended” box and attaching a signed statement explaining the changes. This is important the business telephone, there is another number where you would like to be contacted by IRS, you may for several reasons. If information is not up-to-date on our database, you may not receive important IRS enter that information on this line also, notating that it is the alternative telephone number. information or correspondence. Be sure to fully complete the application and only change the information that is different from what was originally submitted on Form 13551. Therevised Form 13551 Line 14.This line should be completed only if you are using a business mailing address that is different will not change your address of record for tax purposes, nor will it automatically update information from the address entered on Line 12. Note:The same mailing address can not be used for multiple associated with your Employer Identification Number (EIN). It can take up to 90 days to process an business locations. amended application. Line 15. Check the “yes” or “no” box to indicate if the business provides tax related services year round Where to Apply.Faxed copies or photocopies of this application will not be accepted. Mail Form (January through December). If the answer is “no”, provide a brief explanation why the business does 13551, along with your completed fingerprint card or evidence of professional status if required, forensic not provide tax related services year round. document training certificate (if applying as a CAA), and mandatory Acceptance Agent training Line 15a. Enter the volume of Forms W-7 that you anticipate filing during a 12 month calendar period. certificate to: Lines 16 and 17. Enter the name of the primary and alternate contact(s) only if different than the Internal Revenue Service authorized representative(s) of the business (individual listed on Line 5 or on the continuation sheet(s) 3651 S. IH 35 to the application). This is the person that has been authorized by the business to contact the ITIN Stop 6380AUSC Operations to inquire about the status of W-7 applications, but they are not permitted to sign the Form Austin, TX 78741 W-7(COA). Also provide the person’s business title, telephone and fax numbers and their email Note: Be sure that your application is complete and contains the signatures of both the authorized address. Each business location may have one primary and one alternate contact. representative and principal, partner or owner of the originalbusiness. (See instructions for Line 20.) To Line 18.You may attach a separate statement to provide a detailed description of the activities be valid, the mandatory training certification must be dated within 120 days of the date entered on Line performed by the business which would validate this request for Acceptance Agent status. For example, 22. a tax preparation firm preparing U.S. federal income tax returns for nonresident alien real estate Who to Contact for Assistance. If you need additional assistance in completing this application you investors who do not qualify for an SSN, would validate this request for Acceptance Agent status. can email the ITIN Policy Section at itinprogramoffice@irs.gov where someone will respond to you. Line 19. The principal, partner or owner of the business may request to be included on a public list of For additional information about Acceptance Agents, refer to Revenue Procedure 2006-10. For acceptance agents published by the IRS on its website by checking this box. additional information about the Form W-7, see Publication 1915 Understanding Your Individual Lines 20 and 21. Both the authorized representative and the principal, partner or owner must print and Taxpayer Identification Number - ITIN. sign their name on this application. By signing the application you are authorizing the Internal Revenue How To Complete The Form Check the applicable box to indicate if you are (1) a New applicant, (i.e., Service to conduct suitability checks as referenced in the Revenue Procedure. the first time that the business is applying for AA/CAA status or your agreement has already expired), Line 22. Enter the date that this application is signed. (2) seeking Renewal of a AA/CAA Agreement that will be expiring or (3) Amending information on a business that is already an AA/CAA (i.e. submitting an application for a new authorized representative; Pages 3 and 4 – (Continuation sheets) changing primary or alternate contacts, etc.). See Revenue Procedure 2006-10 for additional Note: Must be attached to a Form 13551 when submitted to IRS.Use pages 3 and 4 to add additional information on Acceptance Agents. For additional information on submitting an amended application, authorized representatives or a primary and alternate contact for a business location. If the business see “When to Update Information” above. operates at more than one location, use a separate continuation sheet for each additional office. The continuation pages must also be signed and dated by the Principal, Partner or Owner of the Business (signature space provided on page 4) and each additional authorized representative, pursuant to the signature requirements for Form 13551, Lines 20 and 21. Catalog Number 38262Q www.irs.gov Form 13551 (Rev. 6-2019) |
Page 3 Department of the Treasury - Internal Revenue Service Form 13551 OMB Number (June 2019) Continuation Sheet for Additional Authorized Representatives 1545-1896 (see Form 13551 instructions) Legal Name of the Business (Page 1, Line 2 (and 11, if applicable)) Business EFIN Business EIN Business location address Street City/County State/Country ZIP Code/Foreign Postal Code Information and Signature of Additional Authorized Representative Professional Status of 5. Name and PTIN of Authorized Representative of 6. Date of birth 7. Social Security Number (SSN) or Taxpayer Authorized the Business (first, middle, last, PTIN) (month, day, year) Identification Number (ITIN) Representative (Line 5) Tax Preparer 8. Home address (street, city/county, state/country, 9. Check the appropriate box 10. Have you ever been assessed any preparer CPA* and ZIP code/foreign postal code) of individual penalties, been convicted of a crime, failed to Attorney* listed on Line 5 U.S. Citizen file personal tax returns, or pay tax liabilities, U.S. Resident Alien* or been convicted of any criminal offense Enrolled Agent* under the U.S. Internal Revenue laws Nonresident Alien** number Yes No *Attach copy of green card Other **Attach copy of visa if residing (Attach an explanation and fingerprint cards in the U.S. for a “Yes” response.) *See instructions for proof requirements 13. Business telephone number Fax number 14. Mailing address of the Business if different from the location address on line 12 ( ) ( ) Number and street City/County State/Country ZIP Code/Foreign Postal Code Email Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our participation. Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the institution. Name and title of Authorized Representative from line 5 (type or print) Signature of Authorized Representative Date Information and Signature of Additional Authorized Representative Professional Status of 5. Name and PTIN of Authorized Representative of 6. Date of birth 7. Social Security Number (SSN) or Taxpayer Authorized the Business (first, middle, last, PTIN) (month, day, year) Identification Number (ITIN) Representative (Line 5) Tax Preparer 8. Home address (street, city/county, state/country, 9. Check the appropriate box 10. Have you ever been assessed any preparer CPA* and ZIP code/foreign postal code) of individual penalties, been convicted of a crime, failed to Attorney* listed on Line 5 U.S. Citizen file personal tax returns, or pay tax liabilities, U.S. Resident Alien* or been convicted of any criminal offense Enrolled Agent* under the U.S. Internal Revenue laws Nonresident Alien** number Yes No *Attach copy of green card Other **Attach copy of visa if residing (Attach an explanation and fingerprint cards in the U.S. for a “Yes” response.) *See instructions for proof requirements 13. Business telephone number Fax number 14. Mailing address of the Business if different from the location address on line 12 ( ) ( ) Number and street City/County State/Country ZIP Code/Foreign Postal Code Email Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our participation. Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the institution. Name and title of Authorized Representative from line 5 (type or print) Signature of Authorized Representative Date Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your response is voluntary. 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 code section 6103. The estimated average time to complete this form is 30 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we will be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE: W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224. Do NOT send this form to this address. Instead, enclose it with the magnetic tape and send it to the Service Center to which you submit your tapes or send it to the transmission reception site that received your transmittedreturns. Catalog Number 38262Q www.irs.gov Form 13551 (Rev. 6-2019) |
Page 4 Information and Signature of Additional Authorized Representative Professional Status of 5. Name and PTIN of Authorized Representative of 6. Date of birth 7. Social Security Number (SSN) or Taxpayer Authorized the Business (first, middle, last, PTIN) (month, day, year) Identification Number (ITIN) Representative (Line 5) Tax Preparer 8. Home address (street, city/county, state/country, 9. Check the appropriate box 10. Have you ever been assessed any preparer CPA* and ZIP code/foreign postal code) of individual penalties, been convicted of a crime, failed to Attorney* listed on Line 5 U.S. Citizen file personal tax returns, or pay tax liabilities, U.S. Resident Alien* or been convicted of any criminal offense Enrolled Agent* under the U.S. Internal Revenue laws Nonresident Alien** number Yes No *Attach copy of green card Other **Attach copy of visa if residing (Attach an explanation and fingerprint cards in the U.S. for a “Yes” response.) *See instructions for proof requirements 13. Business telephone number Fax number 14. Mailing address of the Business if different from the location address on line 12 ( ) ( ) Number and street City/County State/Country ZIP Code/Foreign Postal Code Email Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our participation. Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the institution. Name and title of Authorized Representative from line 5 (type or print) Signature of Authorized Representative Date Information and Signature of Additional Authorized Representative Professional Status of 5. Name and PTIN of Authorized Representative of 6. Date of birth 7. Social Security Number (SSN) or Taxpayer Authorized the Business (first, middle, last, PTIN) (month, day, year) Identification Number (ITIN) Representative (Line 5) Tax Preparer 8. Home address (street, city/county, state/country, 9. Check the appropriate box 10. Have you ever been assessed any preparer CPA* and ZIP code/foreign postal code) of individual penalties, been convicted of a crime, failed to Attorney* listed on Line 5 U.S. Citizen file personal tax returns, or pay tax liabilities, U.S. Resident Alien* or been convicted of any criminal offense Enrolled Agent* under the U.S. Internal Revenue laws Nonresident Alien** number Yes No *Attach copy of green card Other **Attach copy of visa if residing (Attach an explanation and fingerprint cards in the U.S. for a “Yes” response.) *See instructions for proof requirements 13. Business telephone number Fax number 14. Mailing address of the Business if different from the location address on line 12 ( ) ( ) Number and street City/County State/Country ZIP Code/Foreign Postal Code Email Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our participation. Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the institution. Name and title of Authorized Representative from line 5 (type or print) Signature of Authorized Representative Date Names and Contact Information for Primary and Alternate Contacts at the business location listed above. (Complete only if primary and alternate contacts for this business location are not already listed as the primary and alternate contacts on page 1, line 16 of the attached Form 13551. 16. Complete information for primary contact if not listed on attached Form 13551 Complete information for alternate contact if not listed on attached Form 13551 Name (first, middle initial, last) and Title Name (first, middle initial, last) and Title Phone number( ) Fax number ( ) Email Phone number( ) Fax number ( ) Email Signature of Principal, Partner or Owner of Business Under the penalties of Perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief, the information being provided is true, correct, and complete. I or my institution and its employees acting on behalf of the institution will comply with all of the provisions of the Revenue Procedure for Acceptance Agents and related publications each year of our participation. Acceptance for participation is not transferable. I understand that if this institution is sold or its organizational structure changes, a new application must be filed. I further understand that noncompliance will result in the institution and/or the individuals listed on this application, being suspended from participation in the IRS Acceptance Agent Program. I am authorized to make and sign this statement on behalf of the institution. Name and title of Principal, Partner or Owner from line 2 (type or print) Signature of Principal, Partner or Owner Date subjectlaw.Privacyaddress.makingGenerally,tothisActInstead,theformandPaperworktaxsimpler,PaperworkenclosereturnsReductionweitandwithwillReductionreturnthebe happyActmagneticinformationunlessActto hearNotice.tapethearefromformandconfidential,Weyou.senddisplaysaskYouitfortoathecantheasvalidinformationrequiredServicewriteOMBto theCentercontrolbyoncodeInternalthistonumber.sectionwhichformRevenuetoyouBooks6103.carrysubmitService,TheoroutrecordstheestimatedyourTaxInternaltapesrelatingProductsaverageorRevenuesendtoCoordinatinga formtimeit tolawsthetoorcompleteofitstransmissiontheinstructionsCommittee,UnitedthisStates.formreceptionmustSE:W:CAR:MP:T:T:SP,isbeYour30retainedsiteminutes.responsethat receivedasIf youlongis voluntary.1111haveasyourtheirConstitutioncommentstransmitted contentsYou areconcerningnotAve.mayreturns.requiredbecomeNW, Washington, thetomaterialaccuracyprovideintheDCofthethisinformation20224.administrationtime DoestimateNOTrequestedofsendoranysuggestionsthisonInternal aformformRevenuetothatforthisis Catalog Number 38262Q www.irs.gov Form 13551 (Rev. 6-2019) |