Declaration Control Number (DCN)

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U.S. Individual Income Tax Declaration OMB No. 1545-0936 8453 for an IRS e-file Return Form

Department of the Treasury

Internal Revenue Service

For the year January 1–December 31, 2001

 See instructions on back.

Use the

IRS label.

Otherwise,

please

print or

type.

Daytime phone number

( )

Tax Return Information (Whole dollars only)

1 Adjusted gross income (Form 1040, line 33; Form 1040A, line 19; Form 1040EZ, line 4) 1

2 Total tax (Form 1040, line 58; Form 1040A, line 36; Form 1040EZ, line 11) 2

3 Federal income tax withheld (Form 1040, line 59; Form 1040A, line 37; Form 1040EZ, line 8) 3

4 Refund (Form 1040, line 68a; Form 1040A, line 43a; Form 1040EZ, line 12a) 4

5 Amount you owe (Form 1040, line 70; Form 1040A, line 45; Form 1040EZ, line 13) 5

Declaration of Taxpayer (Sign only after Part I is completed.)

Under penalties of perjury, I declare that the information I have given my ERO and the amounts in Part I above agree with the amounts on the corresponding

lines of the electronic portion of my 2001 Federal income tax return. To the best of my knowledge and belief, my return is true, correct, and complete. I

consent to my ERO sending my return, this declaration, and accompanying schedules and statements to the IRS. I also consent to the IRS sending my ERO

and/or transmitter an acknowledgment of receipt of transmission and an indication of whether or not my return is accepted, any indication of a refund offset,

and, if rejected, the reason(s) for the rejection. If the processing of my return or refund is delayed, I authorize the IRS to disclose to my ERO and/or transmitter

the reason(s) for the delay, or when the refund was sent.

Sign

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

Declaration of Electronic Return Originator (ERO) and Paid Preparer (See instructions.)

I declare that I have reviewed the above taxpayer’s return and that the entries on Form 8453 are complete and correct to the best of my knowledge. If I am

only a collector, I am not responsible for reviewing the return and only declare that this form accurately reflects the data on the return. The taxpayer will

have signed this form before I submit the return. I will give the taxpayer a copy of all forms and information to be filed with the IRS, and have followed all

other requirements in Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns. If I am also the Paid Preparer, under

penalties of perjury I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge

and belief, they are true, correct, and complete. This Paid Preparer declaration is based on all information of which I have any knowledge.

Date Check ERO’s SSN or PTIN

if selfemployed

ERO’s

ERO’s signature

Use

Only

Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN

Phone no. ( )

Under penalties of perjury, I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my

knowledge and belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.

Date Check Preparer’s SSN or PTIN

if selfemployed

Preparer’s Paid signature

Preparer’s

Use Only

Firm’s name (or

yours if self-employed),

address, and ZIP code Phone no. ( )

Part II

Part I









 EIN

Cat. No. 62766T Form 8453 (2001)

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. If I have filed a joint Federal and state tax return and there is an error on my state return,

I understand my Federal return will be rejected.

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

I consent that my refund be directly deposited as designated in the electronic portion of my 2001 Federal income tax return. If I have filed a joint

return, this is an irrevocable appointment of the other spouse as an agent to receive the refund.

6a

I do not want direct deposit of my refund or I am not receiving a refund.

Check if

also paid

preparer

b

Your first name and initial Last name Your social security number

L

A

B

E

L

H

E

R

E

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

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Important!

City, town or post office, state, and ZIP code

You must enter

your SSN(s) above.



Part III

I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial

institution account indicated in the tax preparation software for payment of my Federal taxes owed on this return and/or a payment of estimated

tax. I further understand that this authorization may apply to subsequent Federal tax payments that I direct to be debited through the Electronic

Federal Tax Payment System (EFTPS). In order for me to initiate subsequent payments, I request that the IRS send me a personal identification

number (PIN) to access EFTPS. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate

the authorization. To revoke a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 business days prior

to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive

confidential information necessary to answer inquiries and resolve issues related to the payment.

c

For Paperwork Reduction Act Notice, see back of form.

2001
Form 8453 (2001) Page 2

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. Enter the box number only if

the post office does not deliver mail to

the taxpayer’s home.

Note: The address must match the

address shown on the 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. 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 on this page.

Part II—Declaration of Taxpayer

An electronically transmitted return will

not be considered complete, and

therefore filed, unless and until a Form

8453 signed by the taxpayer is received

by the IRS.

If the ERO makes changes to the

electronic return after Form 8453 has

been signed by the taxpayer but before

it is transmitted and either 1 or 2 below

applies, the ERO must have the

taxpayer complete and sign a corrected

Form 8453.

1. The adjusted gross income on line 1

differs from the amount on the electronic

return by more than $50 or

2. The total tax on line 2, the Federal

income tax withheld on line 3, the refund

on line 4, or the amount owed on line 5

differs from the amount on the electronic

return by more than $14.

Part III—Declaration of Electronic

Return Originator (ERO) and Paid

Preparer

Line Instructions

Declaration Control Number (DCN).

The DCN is a 14-digit number assigned

by the ERO to each return. Clearly type

or print the DCN in the top left corner of

each Form 8453. Enter the number after

the IRS has acknowledged receipt of the

electronic return as follows:

The IRS requires the ERO’s signature. A

paid preparer must sign Form 8453 in

the space for Paid Preparer’s Use Only.

Only handwritten signatures are

acceptable. But if the paid preparer is

also the ERO, do not complete the paid

preparer’s section. Instead, check the

box labeled “Check if also paid

preparer.”

Boxes Entry

File identification number

(always “00”)

1–2

Refund Information. Refund information

is available on TeleTax. Call

1-800-829-4477.

Electronic filer identification

number (EFIN) assigned by

the IRS

3–8

Batch number (000 to 999)

assigned by the ERO

9–11

Serial number (00 to 99)

assigned by the ERO

12–13

Year digit (for returns filed in

2002, the year digit is “2”)

14

Example. The EFIN is 509325. The

batch number is 000. The serial number

is 56. The DCN is 00-509325-00056-2.

Name and Address. If the taxpayer

received a peel-off name and address

label from the IRS, put the label in the

name area. Cross out any errors and

print the correct information. Add any

missing items, such as apartment

When and Where To File

This form must be mailed to the service

center where the electronic return was

transmitted within 3 business days after

the ERO has received acknowledgment

from the IRS that the return was

accepted. See Pub. 1345A, Filing

Season Supplement for Authorized IRS

e-file Providers, for the address. Only

the Andover, Austin, Cincinnati,

Memphis, and Ogden Service Centers

can accept electronic returns.

Use Form 8453 to:

● Authenticate the electronic portion of

Form 1040, 1040A, or 1040EZ,

● Send any accompanying paper

schedules or statements,

● Authorize the electronic return

originator (ERO) to transmit via a

third-party transmitter, and

● Provide the taxpayer’s consent to

directly deposit any refund and/or

authorize an electronic funds withdrawal

for payment of Federal taxes owed

and/or a payment of estimated tax.

Purpose of Form

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 Internal Revenue Code section 6103.

Refunds. After the IRS has accepted the

return, the refund should be issued

within 3 weeks. However, some refunds

may be delayed because of compliance

reviews to ensure that returns are

accurate.

General Instructions

Note: If the paid preparer’s signature

cannot be obtained on Form 8453, you

may attach a copy of Form 1040,

1040A, or 1040EZ instead. Attach only

pages 1 and 2, and write “COPY—DO

NOT PROCESS” on each page.

Social Security Number (SSN). Be sure

to enter the taxpayer’s SSN in the space

provided on Form 8453. If a joint return,

list the SSNs in the same order as the

first names.

Note: The taxpayer must check all

applicable boxes on line 6.

● Routing number.

● Account number.

● Type of account (checking or savings).

● Debit amount.

● Debit date (date the taxpayer wants

the debit to occur).

If there is an amount on line 5 and the

taxpayer checks box 6b and is paying

by check or money order, mail the

payment by April 15, 2002, with Form

1040-V to the applicable address shown

on that form.

Part I—Tax Return Information

Line 5. Do not include any payment with

Form 8453. The method of payment

depends on whether the taxpayer

checks the box on line 6b or 6c. For

details, see the instructions for Part II.

The taxpayer’s signature allows the

IRS to disclose to the ERO and/or

transmitter the reason(s) for a delay in

processing the return or refund. In the

case of a taxpayer who is applying for a

refund anticipation loan or similar

product, the taxpayer’s signature also

allows the IRS to advise the ERO and/or

transmitter if a refund offset may occur.

If the taxpayer checks box 6c, the

taxpayer must ensure that the following

information relating to the financial

institution account is provided in the tax

preparation software.

Instead of filing Form 8453, the

taxpayer may be able to sign the

return electronically using a

self-selected PIN. For details, go to the

IRS Web Site at www.irs.gov or see

Publication 1345.

number. If the taxpayer did not receive a

label, print or type the information in the

spaces provided.