Form 4506

(Rev. October 1983)

Department of the Treasury — Internal Revenue Service

Request for Copy of Tax Form
or Individual Income Tax Account Informa

OMB Clearance Number
1545-0429

Important: Before completing this form, please read all instructions on the back.

1. Name of taxpayer /s) as shown on tax form

8. Social security or employer identification
number as shown on tax form

2. Current name and address

Spouse's social security number as shown on
tax form

a

Tax form number (Form 1041, 941, etc.)

3. If information is to be mailed to someone else, show the third party’s name

and address

4. If name in third party's records differs from item 1 above, show here

Tax period/s) (No more than 4 per request}

|__|

o

9. Amount due (Make check payable to IRS.)

|

(See instructions for item 3.) Soo
Note: Full payment must accompany your
request
10. (Check only one box}
$5.00 each Copy of tax return and all attachments (including Forms W-2)
Describe Note: If you need these copies certified for court or administrative proceedings,
what you > check here [_] also.
want
$2.50 each C Tax account information only (Do not use for income averaging.)
$2.50 each im Form 1040A or Form 1040EZ verification only
Privacy Act and Paperwork Reduction Act Notice
We ask for this information to carry out the Internal Revenue laws of
the United States. We need the information to gain access to your return
in our files and properly respond to your request. If you do not furnish the
information, we may not be able to fill your request.
Please Telephone number of requester
sign
here a — — —| ( )

Signature

Date

Form 4506 (Rev. 10-83)


Instructions

Use this form to request a copy of a
tax return or individual income tax
account information.

If you are not the taxpayer shown in
item 1, you must send a copy of your

authorization to receive the information.

This will generally be a power of
attorney, tax information authorization,
or evidence of entitlement (for Title 11
Bankruptcy or Recewership Proceeding). If
the taxpayer is deceased, you must
send enough evidence to establish that
you are authorized to act for the
taxpayer's estate.

Tax returns and return information
about joint returns may be disclosed to
either the husband or the wife. Only
one signature is required. If your name
has changed, sign Form 4506 exactly
as your name appeared on the return
and also with your current name.

Corporatians, partnerships, estates,
and trusts.—For rules on who may
obtain tax information on the entity,
see Internal Revenue Code section
6103.

Please allow at least 45 days for
delivery when requesting a copy of a
return, and at least 30 days when
requesting return information or a
verification letter. (You must allow at least
6 weeks processing time after a return is
filed before requesting a copy or other
information.)

Item 3.—If you have named someone
else to receive the information (such as
a CPA, scholarship board, or mortgage
issuer), you must include the name of
an individual with the address in

item 3. Also, be sure and write the
name of the client, student, or
applicant in item 4 if it is different than
the name shown in item 1. For
example, item 1 may be the parents of
a student applying for financial aid,
Show the student's name in item 4 so
the scholarship board will know what
file to associate the return information
with, If we cannot find a record of your
return, we will notify the third party
directly that we cannot fill the request.

Item 5.—For individuals, the social
security number is written 000-00.0000.
For businesses and certain others, the
employer identification number is
written 00-0000000. Please separate the
nine digits as shown, to distinguish the
type of number being reported.

Item 8.—Enter the year(s) of the tax
form you are requesting. For fiscal-year
filers, enter the date the period ended.
{f you need more than four different
periods, use additional request forms.
Returns which were filed six or more
years ago may not be available for
making copies. However, tax account
information is generally still available
for these periods.

Item 9.—Use the following table to
figure how much money you must send
with your request:

Type of Cost foreach
Request period requested
Copy of tax return ..... . . $5.00
Tax account information . 2.50
Form 1040A/1040EZ
verification eee 2.50

Example: You wish to figure your 1983
tax using the income averaging
method, but you do not have a copy of
your 1980 or 1981 returns. Check the
first box in item 10 because you need a
copy of the returns. Your cost will be
$10.00 (85.00 x 2)

Write your social security number or
Federal employer identification number
and “Form 4506 Request” on your
check. If we cannot fill your request, we
will refund your money.

Item 10.—In addition to a copy of a
return, we can provide two other types
of information: a listing of certain tax
account information, or a letter of
verification,

Tax account information only.—
Students applying for financial aid may
be required to give the college a copy
of their tax return. The school may,
however, permit you to use tax return
information provided by the IRS.
instead. If so, the following information
will be sent

(a) Marital status,

(b) Tax shown on return,

(c) Adjusted gross income,

(d) Taxable income,

(e) Self-employment tax, and

(f), Number of exemptions.
Tax account information should not be
used for income averaging, because
the taxable income listed is computed
from the tax table amount as a cross
check, and may vary somewhat from
the return amount. Get a copy of the
return for the exact amount

Form 1040A or 1040EZ verification
only.—States issuing certain qualified
mortgage subsidy bonds are required
to verify that the mortgage applicant
did not own a home during the three
previous years. As part of this
verification, the mortgage issuer may
want proof that you did not claim real
estate interest or tax deductions on a
residence. We will send a letter stating
that Form 1040A or 1040EZ has been
filed for a particular year or years. This
will verify that no itemized deductions
were claimed.

Where to file.—After you have
completed Form 4506, send it to the
service center where the tax return was
filed. The addresses are listed below.

Note: You must use a separate Form
4506 for each service center from which
you are requesting information. You
must also use a separate form if you
request both return information and
return copies.
Please mail to the
following taternal
Revenue Service
1 you ted in Center

Vv Vv

P.O. Box 888
Holtsvile, NY 11742

New Jersey. New York City
‘and counties of Nassau
Rockland, Sullotk, and
Westchester

New York (ail other
counties), Connecticut
Mane, Massachusetts
New Hamipshire, Rhode
Island, Vermont

P.O, Box 3006
Woodburn, MA 01888

Alabama, Florida
Georgaa, Mississippr
South Carolina

P.O, Box 47412
Dovauille. GA 30362

Michigan, Ohio P.O Box 145500

Cincinnaty, OH 45214

Ackansas. Kansas
fousiana, New Mexico
Oklahoma, Texas

Alasxa, Arizona. Colorado,

P.O. Box 2943
Austin, TX 78769

1160 W. 1200 South St

aho. Minnesota. Montana Ogden. UT 84201
Nebraska. Nevada North

Dakota, Gregan, South Dakota

Utah, Washington, Wyorming

Hunors, fowa P.O. Box 1040

Missoun, Wisconsin Kansas Cily. MO 64141

Calforna, Hawa 5045 £ Buller Avenue

Fresno, CA 93888

Indiana. Kentucky. North
Carolina, Tennessee. Virginia
West Virginia

0. Box 2501
Memphis, TN 38101

Delaware. Distict of
Columbia, Maryland
Pennsyivanta, outside the
United States

PO Box 920
Bensalem, PA 19020

Form 4506 (Rev. 10-83)