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
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
Names and addresses shown on last three returns (If different from the information shown on page two (2)).
Form 12339-A (Rev. 5-2006) Catalog Number 28321A
Department of the Treasury-Internal Revenue Service
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.)
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
3. Are you now or have you ever been under investigation for a misdemeanor or possible criminal
4. Have any civil penalties for fraud been assessed against you during the current or last three
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.