## IRS Tax Check Waiver {#irs-tax-check-waiver .TOC-2}

Name:
[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

> OCC Application Number:
> [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

**TAX CHECK WAIVER**

I am signing this waiver to permit the Internal Revenue Service (IRS) to
release information about me which would otherwise be confidential. This
waiver is made pursuant to 26 USC 6103(c).

I request that the IRS release the following information to the
Comptroller of the Currency (*insert district office address*):

Check One:

+-----------------------------------------------------------+----+----+
| 1.  Have I failed to timely file a federal income tax     | □  | □  |
|     return by the required due date (determined with      | Y  | No |
|     regard to any extension of time for filing) for any   | es |    |
|     of the last three years for which the filing of a     |    |    |
|     return might have been 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 the 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.)                                           |    |    |
+-----------------------------------------------------------+----+----+
| 2.  Have I failed to pay any tax, penalty, or interest    | □  | □  |
|     liability during the current or last three calendar   | Y  | No |
|     years within 10 days of the date on which the IRS     | es |    |
|     gave notice of the amount due and requested payment?  |    |    |
+-----------------------------------------------------------+----+----+
| 3\. Am I now or have I ever been under investigation for  | □  | □  |
| a misdemeanor or possible criminal offenses?              | Y  | No |
|                                                           | es |    |
+-----------------------------------------------------------+----+----+
| 4\. Has any civil penalty for fraud been assessed against | □  | □  |
| me during the current or last three calendar years?       | Y  | No |
|                                                           | es |    |
+-----------------------------------------------------------+----+----+
| 5.  If a return for any of the last three years was not   |    |    |
|     filed, explain why. If there was insufficient income  |    |    |
|     to meet filing requirements or filing requirements    |    |    |
|     were met by filing with a foreign tax agency (for     |    |    |
|     example, Puerto Rico or the Virgin Islands), describe |    |    |
|     the circumstances).                                   |    |    |
+-----------------------------------------------------------+----+----+

  -----------------------------------------------------------------------
  To help the IRS find my tax records, I am voluntarily giving the
  following information:

  -----------------------------------------------------------------------

Name (print or type):

Social Security Number (SSN):

Current Home Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone Numbers: (Home) (Work)

(Area Code) (Area Code)

Names and addresses shown on last three years' returns (if different
from above).

[Year]{.underline} [Name]{.underline} [Address]{.underline}

I authorize the IRS to release any additional relevant information
necessary to respond to the questions above.

Date: Signature:

(This consent is valid only if received (Signature of taxpayer
authorizing the

by the IRS within 60 days of this date.) disclosure of confidential tax
information)

**If married and filing a joint return:**

Spouse's Name Spouse SSN:

Date: Signature:

(This consent is valid only if received (Signature of taxpayer
authorizing the

by the IRS within 60 days of this date.) disclosure of confidential tax
information)

Your social security number (and that of your spouse when joint returns
have been filed) is requested to allow the Comptroller of the Currency
to determine whether your Federal tax obligations have been fulfilled as
part of its consideration of your suitability for a position as
shareholder, officer, director, employee, or agent of a national bank or
a Federal branch or agency. This information may be disclosed to other
persons or governmental authorities.

Our authority for requesting this information is 12 U.S.C. § 1
[et]{.underline} [seq.]{.underline} and Executive Order 9397. Your
provision of this information is voluntary. However, if you do not
provide us with this information, it may adversely affect our ability to
consider you.