Internal Revenue Service
Disclosure Scanning Operation
Stop 93A
Post Office Box 621506
Atlanta, GA 30362-3006
1. Name of employee making request Date request made
2. Group Manager Signature Group Manager phone number
SECTION B
Request for Return / Information
(Federal/State Tax Exchange Program - State and Local Government Use Only)
Return to
I am requesting the following identified return(s) / return information under terms of the Federal / State Tax Coordination
Agreement. I understand disclosure or use of the information received for other than authorized tax administrative purposes
is subject to criminal and civil liabilities under sections 7213 and 7431 of the Internal Revenue Code.
1. Name of Taxpayer SSN / ElN
Address
2. Information Requested Tax periods Type of return forms
Yes No
Copy of return(s)
Transcript
Audit Workpapers
Outstanding balance of assessments including penalties and interest computed to
(date)
Other (Specify below)
3. Reason requested (Check the appropriate block)
Pending Examination
Pending Collection Activity
Other (Specify)
Criminal Investigation
Telephone number Date signed3. From (Signature l Authorized Representative)
4. Requesting Agency
SECTION ASECTION C
Check the appropriate block
Form
8796-A (9-2011) Catalog Number 58558D
Department of the Treasury-Internal Revenue Service
www.irs.gov
Division / Branch / Group
Attention
Street address
Street address
City, State, ZIP code
Agency name
The form may be used by state and local tax agency personnel requesting return(s) or return information from IRS.
Complete Sections A, B and C. After signature approval, forward to the pre-printed address in Section A. State the agency's need and use for the
requested data as specifically as possible in section B-3. A general statement that it is needed for tax administration is insufficient.
Note: Do not send expedite requests or other requests that require local handling to the address in Section A. Contact your local Disclosure Office.
If the office agrees to expedite or otherwise handle your request locally, you will submit it directly to that office.
Instructions for Form 8796-A, Request for Returns/Information under Federal/State Exchange Agreement
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signature
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signature
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