OMB No. 1545-1791
I am signing this waiver to permit the Internal Revenue Service (IRS) to release information about me which would
otherwise be confidential. This information will be used in connection with my application for appointment to membership
in the IRS Advisory Council/Information Reporting Program Advisory Committee. This waiver is made pursuant to 26
U.S.C. 6103(c).
I request that the IRS' Office of Government Liaison and Disclosure release the following information to the appropriate
IRS officials, including, but not limited to, the Director, National Public Liaison.
Check only one
box per question
NoYes
Names and addresses shown on last three returns (If different from the information shown on page two (2)).
Year AddressName(s)
1. 20
Form 12339-A (Rev. 5-2006) Catalog Number 28321A
Department of the Treasury-Internal Revenue Service
www.irs.gov
Tax Check Waiver
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
might have been 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 the 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.)
NoYes
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
NoYes
3. Are you now or have you ever been under investigation for a misdemeanor or possible criminal
offenses
NoYes
4. Have any civil penalties for fraud been assessed against you during the current or last three
calendar years
NoYes
5. If a return for any of the last three years was not filed, please explain why?
If there was insufficient income to meet filing requirements or filing requirements were met by filing
with a foreign tax agency (e.g., Puerto Rico or the Virgin Islands), please describe the
circumstances in the Comments Section on page 2.
2. 20
2. 20
Comments (If you answered ''Yes'' to any question on page one (1), please explain why)
I authorize the IRS to release any additional relevant information necessary to respond to the questions on page one (1).
To help the IRS find my tax records, I am voluntarily providing the following information (please type or print).
Name
Social Security Number
PRIVACY ACT STATEMENT
Form 12339-A (Rev. 5-2006) Catalog Number 28321A
Department of the Treasury-Internal Revenue Service
www.irs.gov
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 your 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.
Home street address
City State ZIP Code
Home telephone number
Business/Work telephone number
Applicant signature (Signature of the applicant authorizing the disclosure of confidential tax information)
Date signed (This consent is valid only if received by the IRS within sixty (60) calendar days of this date)
If you are married and file a joint Federal tax return, your Spouse must provide the following information
Spouse's name
Social Security Number
Spouse's signature (Signature of the spouse authorizing the disclosure of confidential tax information)
Date signed (This consent is valid only if received by the IRS within sixty (60) calendar days of this date)
click to sign
signature
click to edit
dd mmm yyyy
click to sign
signature
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dd mmm yyyy
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