(Rev. November 2013)
Department of the Treasury
Internal Revenue Service
Application for Voluntary
Classification Settlement Program (VCSP)
Do not send payment with Form 8952.
Information about Form 8952 and its separate instructions is at www.irs.gov/form8952.
OMB No. 1545-2215
Caution. Taxpayer must make certain representations in order to be eligible to participate in the VCSP. These representations can be found in
Part V on page 2.
Part I Taxpayer Information
1 Taxpayer's name 2 Employer identification number (EIN)
Number and street (or P.O. box number if mail is not delivered to a street address) Room/Suite
City, town or post office, state, and ZIP code
Telephone number 6 Website address (optional)
Fax number (optional) 8 Email address (optional)
9 Type of entity.
Check the applicable box:
Cooperative organization described in section 1381 of the Internal Revenue Code
State or local government (for worker class or position not covered under a section 218 agreement)
Other (specify here)
10 Are you a member of an affiliated group?
If “Yes,” complete the common parent information on lines 11-14.
If “No,” skip to Part II.
Name of common parent of the affiliated group 12 EIN of common parent
Number and street (or P.O. box number if mail is not delivered to a street address) of common parent
City, town or post office, state, and ZIP code of common parent
Part II Contact Person
Attach a properly completed Form 2848, Power of Attorney and Declaration of Representative, if applicable. Also see Special
instructions for Form 2848 in the instructions.
• Name and title of contact person
• Contact person's number and street (or P.O. box number if mail is not delivered to a street address)
• Contact person's city, town or post office, state, and ZIP code
• Contact person's telephone number
• Contact person's fax number (optional)
• Contact person's email address (optional)
Part III General Information About Workers To Be Reclassified
15 Enter the total number of workers from all classes
to be reclassified. A class of workers includes all
workers who perform the same or similar
Enter a description of the class or classes of workers to be reclassified. If
more space is needed, attach separate sheets (see instructions).
17 Enter the beginning date of the employment tax
period (calendar year or quarter) for which you
want to begin treating the class or classes of
workers as employees. This date should be at
least 60 days after the date you file Form 8952
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 37772H
Form 8952 (Rev. 11-2013)