Declaration Control Number (DCN)

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U.S. Individual Income Tax Declaration OMB No. 1545-1397 8453-OL for On-Line Service Electronic Filing

Form

Department of the Treasury

Internal Revenue Service

For the year January 1–December 31, 1995

© See instructions on back.

Your first name and initial Last name Your social security number L

A

B

E

L

H

E

R

E

Use the

IRS label.

Otherwise,

please

print or

type.

If a joint return, spouse’s first name and initial Last name Spouse’s social security number

Home address (number and street). If a P.O. box, see instructions. Apt. no. Telephone number (optional)

( )

City, town or post office, state, and ZIP code For Paperwork Reduction Act

Notice, see instructions.

Tax Return Information (Whole dollars only)

1 Total income (Form 1040, line 22; Form 1040A, line 14; Form 1040EZ, line 4) 1

2 Total tax (Form 1040, line 54; Form 1040A, line 28; Form 1040EZ, line 10) 2

Federal income tax withheld (Form 1040, line 55; Form 1040A, line 29a; Form 1040EZ, line 7). If

any is from Form(s) 1099, check here ©

3

3

4 Refund (Form 1040, line 63; Form 1040A, line 31; Form 1040EZ, line 11) 4

5 Amount you owe (Form 1040, line 65; Form 1040A, line 33; Form 1040EZ, line 12) 5

Direct Deposit of Refund (Optional—See instructions.)

6 Name of financial institution and, if applicable, branch name ©

7 Routing transit number (RTN)

The first two numbers of the RTN must

be 01 through 12 or 21 through 32.

8 Depositor account number (DAN)

10 Ownership of account:

Attach Copy B of your Forms

W-2, W-2G, and 1099-R here.

Self Spouse Self and Spouse

Declaration of Taxpayer

If I have completed Part II above, I consent that my refund be directly deposited as designated in Part II, and declare that the

information on lines 6 through 10 is correct. If I have filed a joint return, this is an irrevocable appointment of the other spouse as

an agent to receive the refund.

Sign

Here © Your signature Date Spouse’s signature. If a joint return, BOTH must sign. Date

Part III

Part II

Part I

©

Cat. No. 15907C Form 8453-OL (1995)

IRS Use Only—Do not write or staple in this space.

Under penalties of perjury, I declare that the information I have given my on-line service provider (OLSP) or transmitter and the

amounts in Part I above agree with the amounts on the corresponding lines of the electronic portion of my 1995 Federal income

tax return. To the best of my knowledge and belief, my return is true, correct, and complete. I consent that the electronic portion

of my return be sent to the IRS by my OLSP or transmitter. I also consent to the IRS sending to my OLSP or transmitter an

acknowledgment of receipt of transmission and an indication of whether or not my return is accepted and, if rejected, the reason(s)

for the rejection.

9 Type of account: Savings Checking

If I have filed a balance due return, I understand that if the IRS does not receive full and timely payment of my tax liability, I will

remain liable for the tax liability and all applicable interest and penalties.
Form 8453-OL (1995) Page 2

Caution: The account cannot include

the name of any other person except as

noted above.

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.

P.O. Box. If the post office does not

deliver mail to your home and you have

a P.O. box, enter the box number.

Some financial institutions will not

allow a joint refund to be deposited into

an individual account. The IRS is not

responsible when a financial institution

refuses a direct deposit for this reason. Note: The address must match the

address shown on your electronically

filed return.

The time needed to complete and file

this form will vary depending on

individual circumstances. The estimated

average time is 15 minutes.

Part I—Tax Return Information

Part III—Declaration of Taxpayer

If you have comments concerning the

accuracy of this time estimate or

suggestions for making this form

simpler, we would be happy to hear from

you. You can write to the Tax Forms

Committee, Western Area Distribution

Center, Rancho Cordova, CA

95743-0001. DO NOT send the form to

this address. Instead, see When and

Where To File below.

Line 5. Do not attach your check or

money order to Form 8453-OL. Instead,

mail it by April 15, 1996, with Form

1040-V, Payment Voucher, to the Internal

Revenue Service, P.O. Box 970016, St.

Louis, MO 63197-0016. You may have

received a Form 1040-V with your tax

package. If not, you may be able to get

Form 1040-V from your OLSP or

transmitter or you can call the IRS at

1-800-TAX-FORM (1-800-829-3676).

Your electronically transmitted return will

not be considered complete, and

therefore filed, unless and until the IRS

receives your signed Form 8453-OL. If a

joint return, your spouse must also sign.

Part II—Direct Deposit of Refund

Complete this part if you choose to have

your refund directly deposited. Your

routing transit number (RTN) and

depositor account number (DAN) may be

shown on the bottom left of your check.

Line 7. The RTN must be nine digits. If it

does not begin with 01 through 12 or 21

through 32, your direct deposit will be

rejected and a check sent.

Line 8. The DAN can be up to 17

characters (both numbers and letters).

Include hyphens but omit spaces and

special symbols. If fewer than 17

characters, enter the number from left to

right and leave the unused boxes blank.

Line 3. If you have any withholding from

Form(s) 1099, include it in the amount

you enter on line 3 and check the box.

Line Instructions

Declaration Control Number (DCN).

The DCN is a 14-digit number assigned

to your return by your OLSP or

transmitter. It is included in your

acknowledgment message. Clearly type

or print the DCN in the top left corner of

Form 8453-OL. The number should be in

the following format:

Refunds. Your refund should be issued

within 21 days after the IRS has

accepted your return. However, some

refunds may be delayed because of

compliance reviews to ensure that

returns are accurate.

Boxes Entry

File identification number

(always “00”)

1–2

Automated Refund Information.

Refund information is available on

Tele-Tax. If you live in Kansas, New

Mexico, Oklahoma, or Texas, you may

call 1-800-829-4477. If you don’t live in

one of these states, you may call either

214-767-1792 or 713-541-3400. These

are not toll-free calls. If your refund is

delayed or you don’t get complete

information from Tele-Tax, you may call

the Austin Service Center at

512-462-8900 (Ext. 7197). This is not a

toll-free call.

Electronic filer identification

number (EFIN) assigned to

your OLSP or transmitter by

the IRS

3–8

Batch number (000 to 999)

assigned by your OLSP or

transmitter

9–11

Serial number (00 to 99)

assigned by your OLSP or

transmitter

12–13

Note: Some financial institutions may not

accept direct deposits into accounts that

are payable through another bank or

financial institution, including credit

unions.

Year digit (for returns filed in

1996, the year digit is “6”)

14

Line 10. The account designated to

receive the direct deposit must be in

your name. If you are married filing

jointly, the account can be in either

name or both your names. If you are

married filing separately, the account

can be in your name or in both your

name and your spouse’s name.

Example. The EFIN is 509325. The

batch number is 000. The serial number

is 56. The DCN is 00-509325-00056-6.

Name, Address, and Social Security

Number (SSN). If you received a

peel-off label from the IRS, place it in

the name area. Cross out any errors and

print the correct information. Add any

missing items, such as apartment

number. If you did not receive a label,

print or type the information in the

spaces provided. Make sure your SSN is

clear and correct. An incorrect or

missing SSN may delay any refund. If a

joint return, be sure the names and

SSNs are listed in the same order.

When and Where To File

You must mail this form to your OLSP or

transmitter on the next working day after

you have received acknowledgment from

your OLSP or transmitter that the IRS

has accepted your electronically filed

return. The address should be included

in your acknowledgment message.

Printed on recycled paper

Purpose of Form

Use Form 8453-OL to:

● Authenticate the electronic portion of

Form 1040, 1040A, or 1040EZ,

● Send any accompanying paper

schedules and statements, and

● Request that we directly deposit any

refund into your bank account.

Who Must File

If you are filing a 1995 Form 1040,

1040A, or 1040EZ through an on-line

service provider (OLSP) or transmitter,

you must file a signed 1995 Form

8453-OL.

For accounts payable through a

financial institution other than the one at

which the account is located, you must

enter the RTN of the bank or institution

where the account is located. You may

find this information on your account

statement or account identification card.

If you have any doubt about the

correct RTN, contact your financial

institution and ask for the correct RTN

for direct deposit (Electronic Funds

Transfers).