Catalog Number 58763Y www.irs.gov
12339-C (Rev. 8-2017)
PART IV - Other IRS Councils/Committees
Have you ever been a member of the Internal Revenue Service Advisory Council (formerly known as Commissioner's Advisory Group),
Art Advisory Panel, Electronic Tax Administration Advisory Committee, Tax Exempt & Government Entities Advisory Committee or
Information Reporting Program Advisory Committee? If so, please include name of the councils/committees and dates of membership.
Council/Committee name Dates of membership
PART V - Applicant Acknowledgement
I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete and made in good faith. Upon
request, I agree to submit a Tax Check Waiver Form.
Applicant signature Date signed
Privacy Act Statement
The Privacy Act of 1974 requires that when we ask you for 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 for the information is Public Law 92-463 and Executive Order (E.O.) 9397. We are asking for the information
in order to perform Federal income tax, FBI, and practitioner checks as required of all members and applicants to the Advisory Council/Committee.
Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership in the IRS
Advisory Council/Committee. Requesting your social security number, which is solicited under authority of 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. However, not providing all or any part of the information may limit
consideration of your application.
Paperwork Reduction Act Notice
Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to
give us the information. We need it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of tax. 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 section 6103.The time needed to complete and
file this form will vary depending on individual circumstances. The estimated average time is shown below. The estimated burden for all other taxpayers
who file this form is approved under OMB control number 1545-1791.
Preparing, copying, assembling, and sending the form to the IRS …………………….. 10 mins.
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from
you. You can write to: Internal Revenue Service, Tax Exempt and Government Entities, SE:T:CL/NCA 676, 1111 Constitution Avenue, NW, Washington
DC 20224. Do not send the form to this address. Instead, see the return address on the form.
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