Catalog Number 16974D
Form 921 (Rev. 07-2001)
Instructions for Internal Revenue Service Employees
The signature and title line must be signed and dated by the appropriate authorized official within your division.
SMALL BUSINESS/SELF-EMPLOYED DIVISION
Enter the name and title of your business unit executive (e.g., Area Director; Director, Compliance Policy; or Director,
Compliance Services). Secure signature of authorized division official.
WAGE AND INVESTMENT DIVISION
Enter the name and title of your business unit executive (e.g., Area Director or Director, Field Compliance Services).
Secure signature of authorized division official.
LARGE AND MID-SIZE BUSINESS ENTITIES DIVISION
Enter the name and title of your business unit executive (e.g., Director, Field Compliance). Secure signature of
authorized division official.
TAX EXEMPT AND GOVERNMENT ENTITIES DIVISION
Enter the name and title of your business unit executive (e.g., Director, Exempt Organizations; Director, Employee
Plans; Director, Federal, State and Local Governments; Director, Indian Tribal Governments; or Director, Tax Exempt
Bonds). Secure signature of authorized division official.
APPEALS DIVISION
Enter the name and title of your business unit executive (e.g., Director, Appeals Operating Unit). Secure signature of
authorized division official.
Instructions for Taxpayer(s)
Please sign and return the original and copy of Form 921, Consent to Extend the Time to Assess Income Tax, to apply
for an extension in accordance with Revenue Procedure 92-29 and its successors. Your signature(s) must match the
name(s) as it appears on this form.
If the taxpayer named on this consent form is a corporation, the officer(s) duly authorized to sign on behalf of the entity
must sign the consent. Include the name of the corporation and signature/ title of the corporate officer(s).
If this consent form includes tax years where a joint return was filed, the signature of both husband and wife is required.
One spouse may sign as agent for the other, if acting under an authorized power of attorney.
If you're an attorney or agent for the taxpayer(s), you may sign the consent form provided the action is specifically
authorized by a power of attorney. If you haven't filed a power of attorney, please include it with this form.
If you're acting as a fiduciary (executor, administrator, trustee, etc.) you must include a completed Form 56, Notice
Concerning Fiduciary Relationship, if you haven't already filed one.
If you're an entity subject to the unified audit and litigation procedures for TEFRA (Tax Equity and Fiscal
Responsibility Act) partnerships, you must use Form 921-P. If you're an entity not subject to the TEFRA
requirements (namely S-Corporations, partnerships, limited liability companies, trusts, syndicates, pools, etc.), you must
use Form 921-I.