Catalog Number 48518X
12339-B (Rev. 4-2017)
Form 12339-B
(April 2017)
Department of the Treasury - Internal Revenue Service
Information Reporting Program Advisory Committee
Membership Application
OMB Number
Complete this application and return it to the address below no later than Close of Business on May 21, 2017.
You may also e-mail your application to:
Internal Revenue Service
National Public Liaison
CL: NPL – Room 7559 IR
Attn: IRPAC Program Manager
1111 Constitution Avenue, N.W.
Washington, DC 20224
PART I – Applicant Information (Some of the information requested in Part I is required to perform an FBI background check)
Name Maiden name or other name(s) used Date(s) names were used
Home street address Home telephone number
City State ZIP Code
Date of birth (mm-dd-yyyy) City of birth State of birth
Business name
Business address Job title
City State ZIP Code
Business telephone number Business FAX number Email address
PART II – Applicant must complete and submit Form 13775, Tax Check Waiver, with this form
PART III – Desired Skills and Qualifications
Submit a brief statement addressing your past or current affiliations and dealings with a particular organization or group that you
represent and how such dealings will allow you to know the view's or position of that particular organization or group. In addition, submit
a short (one or two page) statement, including recent examples, addressing your specific skills and qualifications as they relate to the
Experience working with tax information reporting.
Experience developing and presenting issue resolution and recommendations.
Experience developing and implementing customer service initiatives and tools.
Experience in change management and improvement.
Experience establishing successful strategic partnerships.
Ability to examine issues from a macro viewpoint, and effectively communicate recommendations.
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Catalog Number 48518X
12339-B (Rev. 4-2017)
PART IV – Applicant Resume
Attach a copy of your resume, including prior Treasury and/or IRS employment. State position
(s), title(s), and dates of employment.
Additionally, list professional credentials, membership in professional organizations, and local liaison activities with IRS, if applicable.
PART V – 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 Advisory Committee or Information Reporting Program
Advisory Committee? If so, include name of the councils/committees and dates of membership.
Councils/Committee name Dates of Membership
PART VI – 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.
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
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 …………………… 1 hour., 30 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, 1111 Constitution, Ave, NW, Washington, DC 20224. Do not send the form to this address. Instead,
see the return address on the form.
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click to sign
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