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Federal Free Printable Form 13775 (Rev. 1-2015) for 2019 Federal Tax Check Waiver

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Tax Check Waiver
Form 13775 (Rev. 1-2015)

Form 13775 (January 2015) Department of the Treasury - Internal Revenue Service OMB Number 1545-1791 Tax Check Waiver The purpose of this form is to permit the Internal Revenue Service (IRS) to release information about the applicant which would otherwise be confidential. This information will be used in connection with my application for appointment to membership in one of the IRS Advisory Committee/Council. This waiver is made pursuant to 26 U.S.C. 6103(c). Name of applicant Name of the IRS Advisory Committee/Council for which you are applying or continuing in membership Internal IRS USE ONLY: Completed by the IRS Advisory Committee/Council Program Manager Name and title of the authorized official You are required to answer all the following questions: Check Only One Box 1. Have you failed to timely file a Federal income tax return by the required due date (determined with regard to any extension(s) of time for filing) for any of the last three years for which filing of a return was required? (NOTE: If the filing date [without regard to extensions] and normal processing period for the most recent year's return has not yet elapsed on the date IRS receives this waiver, and IRS records do not indicate a return for the most recent year, the "last three years" will mean the three years preceding the year for which returns are currently being filed and processed.) Yes No 2. Have you failed to pay any tax, penalty, or interest liability during the current or last three calendar years within ten (10) days of the date on which the IRS gave notice of the amount due and requested payment Yes No 3. Are you now or have you ever been under investigation for a misdemeanor or criminal offenses Yes No 4. Have any civil penalties for fraud been assessed against you during the current or last three calendar years Yes No Comments (If you answered "Yes" to question 1, 2, 3, or 4, provide your explanation below. You may also use this space to address any other tax compliance issue you believe is pertinent to this application.) Provide the names and addresses shown on your last three tax returns (if different from the information provided in the Applicant Address and Signature section on page two). Year 1. 20 2. 20 3. 20 Name(s) Catalog Number 48048G Address www.irs.gov Form 13775 (Rev. 1-2015) Page 2 Applicant Address and Signature I request and authorize the IRS' Office of Governmental Liaison and Disclosure to release tax return and any relevant information necessary to respond to the questions on page one to the appropriate IRS officials. To help the IRS find my tax records, I am voluntarily giving the following information (type or print your information). Applicant name Applicant Social Security Number Home address City State ZIP code Home telephone number (include area code) Business/Work telephone number (include area code) Applicant signature Date signed (Signature of the applicant authorizing the disclosure of confidential tax information.) (This consent is valid only if received by the IRS within 120 days of this date.) If married and filing a Joint Return (Spouse must complete the following information) Spouse's name Spouse's Social Security Number Spouse's signature Date signed (If married and filing a Joint Return - Spouse's Signature is required.) (This consent is valid only if received by the IRS within 120 days of this date.) Privacy Act Statement The Privacy Act of 1974 requires that when we ask you 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 you for the information is 5 U.S.C. 301 and Executive Order (E.O.) 9397. We are asking for this information to determine your suitability as an employee (direct hire or contracted), consultant or advisor of the Internal Revenue Service. If you do not provide us with this information, it may adversely affect our ability to consider you. Any adverse information will be shared with the appropriate IRS office(s) and may be disclosed to other federal agencies as required by law. Requesting you Social Security Number, under authority 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. 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. Catalog Number 48048G www.irs.gov Form 13775 (Rev. 1-2015)
Extracted from PDF file 2018-federal-form-13775.pdf, last modified March 2015

More about the Federal Form 13775 Other TY 2018

We last updated the Tax Check Waiver in February 2019, so this is the latest version of Form 13775, fully updated for tax year 2018. You can download or print current or past-year PDFs of Form 13775 directly from TaxFormFinder. You can print other Federal tax forms here.

Other Federal Other Forms:

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Form 8962 Premium Tax Credit
Form W-4V Voluntary Withholding Request
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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 13775 from the Internal Revenue Service in February 2019.

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Historical Past-Year Versions of Federal Form 13775

We have a total of six past-year versions of Form 13775 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2018 Form 13775

Form 13775 (Rev. 1-2015)

2017 Form 13775

Form 13775 (Rev. 1-2015)

2016 Form 13775

Form 13775 (Rev. 1-2015)

Tax Check Waiver 2015 Form 13775

Form 13775 (Rev. 1-2015)

Tax Check Waiver 2012 Form 13775

Form 13775 (Rev. 11-2012)

Tax Check Waiver 2011 Form 13775

Form 13775 (Rev. 12-2010)


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