Department of the Treasury - Internal Revenue Service In reply refer to:

Form SS-10 Consent to Extend the Time to Assess

Employment Taxes

Taxpayer Identification Number (Rev. May 2002)

, taxpayer(s)

(Name(s))

of and the

(Number, Street, City or Town, State, ZIP Code)

Commissioner of Internal Revenue consent and agree to the following:

(1) The amount of taxes due from the taxpayer under:

(a) The Federal Unemployment Tax Act, for calendar years

(b) The Federal Insurance Contributions Act, for tax periods

from through

(c) The income tax withholding provisions of existing or prior revenue laws, for tax periods

from through

(d) The Railroad Retirement Tax Act, for tax periods

from through

plus any applicable additions to the tax, may be assessed at any time on or before

(Expiration date)

Catalog No. 20030G Form SS-10 (Rev. 5-2002)

(2) The collection provisions and limitations now in effect will also apply to any tax assessed within the extended period.

(3) The taxpayer(s) may file a claim for credit or refund and the Service may credit or refund the tax within 6 months after

this agreement ends.

(Signature instructions are on the back of this form)

MAKING THIS CONSENT WILL NOT DEPRIVE THE TAXPAYER(S) OF ANY APPEAL

RIGHTS TO WHICH THEY WOULD OTHERWISE BE ENTITLED.

YOUR SIGNATURE HERE

TAXPAYER'S REPRESENTATIVE

SIGN HERE

(Title) (Date signed)

(Title) (Date signed)

BY

(Authorized Official Signature and Title - see instructions) (Date signed)

CORPORATE

NAME

CORPORATE

OFFICER(S)

SIGN HERE

(Division Executive Name - see instructions) (Division Executive Title - see instructions)

INTERNAL REVENUE SERVICE SIGNATURE AND TITLE

(Date signed)

(Date signed)

www.irs.gov
Instructions

Form SS-10 (Rev. 5-2002)

If this consent is for a partnership return, only one authorized partner need sign.

If you are an attorney or agent of the taxpayer(s), you may sign this consent

provided the action is specifically authorized by a power of attorney. If the power of

attorney was not previously filed, you must include it with this form.

If you are acting as a fiduciary (such as executor, administrator, trustee, etc.) and

you sign this consent, attach Form 56, Notice Concerning Fiduciary Relationship,

unless it was previously filed.

If the taxpayer is a corporation, sign this consent with the corporate name followed

by the signature and title of the officer(s) authorized to sign.

Instructions for Internal Revenue Service Employees

Complete the Division Executive's name and title depending upon your division.

If you are in the Small Business /Self-Employed Division, enter the name and title

for the appropriate division executive for your business unit (e.g., Area Director for

your area; Director, Compliance Policy; Director, Compliance Services).

If you are in the Wage and Investment Division, enter the name and title for the

appropriate division executive for your business unit (e.g., Area Director for your

area; Director, Field Compliance Services).

If you are in the Large and Mid-Size Business Division, enter the name and title for

the appropriate division executive for your business unit (e.g., Director, Field

Operations for your industry; Director, Field Specialists).

If you are in the Tax Exempt and Government Entities Division, enter the name and

title for the appropriate division executive for your business unit (e.g., Director,

Exempt Organizations; Director, Employee Plans; Director, Federal, State and

Local Governments; Director, Indian Tribal Governments; Director, Tax Exempt

Bonds).

If you are in Appeals, enter the name and title of the appropriate Director, Appeals

Operating Unit.

The signature and title line will be signed and dated by the appropriate authorized

official within your division.

Catalog No. 20030G