O

Exempt Organization Declaration and Signature for

Electronic Filing Form 8453-EO

Department of the Treasury

Internal Revenue Service

For calendar year 2004, or tax year beginning , 2004, and ending , 20

Name of exempt organization Employer ide

Type of Return and Return Information (Whole Dollars Only)

Declaration of Officer

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

For Paperwork Reduction Act Notice, see back of form. Cat. No. 36606Q For

Part III

Part I

Part II

For use with Forms 990, 990-EZ, 990-PF, 1120-POL, and 8868

Check the box for the return for which you are using this Form 8453-EO and enter the applicable amount from t

any. If you check the box on line 1a, 2a, 3a, 4a, or 5a below and the amount on that line for the return for wh

filing this form was blank, then leave line 1b, 2b, 3b, 4b, or 5b whichever is applicable, blank (i.e. do not enter 

you entered -0- on the return, then enter -0- on the applicable line below. Do not complete more than 1 line in 

Sign

Here  Signature of officer Title

Date Check ERO’s S

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 return and accompanying schedules and statements, and to the 

and belief, they are true, correct, and complete. Declaration of preparer is based on all information of which the preparer has any kno

Date Check Prepare

if selfemployed

Preparer’s Paid signature

Preparer’s

Use Only

Firm’s name (or

yours if self-employed),

address, and ZIP code









 EIN

Check if

also paid

preparer

I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawa

to the financial institution account indicated in the tax preparation software for payment of the organization’s 

on this return, and the financial institution to debit the entry to this account. To revoke a payment, I must contac

Financial Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement) date. I also au

institutions involved in the processing of the electronic payment of taxes to receive confidential information n

inquiries and resolve issues related to the payment.

 See instructions on back.

Under penalties of perjury, I declare that I am an officer of the above named organization and that I have examin

organization’s 2004 electronic return and accompanying schedules and statements and to the best of my knowledge a

true, correct, and complete. I further declare that the amount in Part I above is the amount shown on the copy of 

electronic return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (

organization’s return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection o

(b) an indication of any refund offset, (c) the reason for any delay in processing the return or refund, and (d) the date 

I declare that I have reviewed the above organization’s return and that the entries on Form 8453-EO are complete and 

of my knowledge. If I am only a collector, I am not responsible for reviewing the return and only declare that this form 

the data on the return. The organization officer will have signed this form before I submit the return. I will give the o

forms and information to be filed with the IRS, and have followed all other requirements in Publication 4206, Modernize

for Authorized IRS e-file Providers for Exempt Organization Filings. If I am also the Paid Preparer, under penalties of pe

I have examined the above organization’s return and accompanying schedules and statements, and to the best of 

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

Phone no. ( 

Date

1a Form 990 check here  b Total revenue, if any (Form 990, line 12) 1b

2a Form 990-EZ check here  b Total revenue, if any (Form 990-EZ, line 9) 2b

3a Form 1120-POL check here  b Total tax (Form 1120-POL, line 22) 3b

4a Form 990-PF check here  b Tax based on investment Income (Form 990-PF, Part VI, line 5) 4b

5a Form 8868 check here  b Balance Due (Form 8868, line 3c) 5b

6
Privacy Act and Paperwork Reduction Ac

for the information on this form to carry out 

Revenue laws of the United States. You are 

us the information. We need it to ensure tha

complying with these laws and to allow us t

collect the right amount of tax. Section 610

preparers to provide their identifying numbe

The time needed to complete and file this 

depending on individual circumstances. The 

average time is:

Part II—Declaration of Officer

Part III—Declaration of Electro

Originator (ERO) and Paid Prep

How To File

When To File

Form 990, 990-EZ, and Form 990-PF. File Form 990, Form

990-EZ, or Form 990-PF by the 15th day of the 5th month after

the organization’s accounting period ends. If the regular due

date falls on a Saturday, Sunday, or legal holiday, the

organization may file on the next business day.

Use Form 8453-EO to:

● Authorize the electronic return originator (ERO), if any, to

transmit via a third-party transmitter;

● Authorize an electronic funds withdrawal for payment of

federal taxes owed (Form 990-PF, Form 1120-POL, or Form

8868 with payment).

Purpose of Form

You are not required to provide the inform

on a form that is subject to the Paperwork 

unless the form displays a valid OMB contr

or records relating to a form or its instructio

retained as long as their contents may beco

the administration of any Internal Revenue l

governing the confidentiality of the Form 99

and Form 990-PF are covered in Code sect

Generally, tax returns (Form 1120-POL) and 

information are confidential, as required by 

Code section 6103.

If a Form 1120-POL or Form 8868 filer chooses to pay the

tax due by electronic funds withdrawal (direct debit), check

the box. Otherwise, leave the box blank.

Form 8453-EO (2004) 

The Form 8453-EO must be filed with the electronically

filed Form 990, Form 990-EZ, or Form 990-PF.

Form 1120-POL. File Form 1120-POL by the 15th day of the

3rd month after the organization’s accounting period ends. If

the regular due date falls on a Saturday, Sunday, or legal

holiday, the organization may file on the next business day.

The Form 8453-EO must be filed with the electronically

filed Form 1120-POL.

Recordkeeping 

Learning about the law or the form 

Preparing, copying, assembling, 

and sending the form to the IRS 

If you have comments concerning the acc

time estimates or suggestions for making th

we would be happy to hear from you. You c

Internal Revenue Service, Tax Products Coo

Committee, SE:W:CAR:MP:T:T:SP, 1111 Co

NW, IR 6406, Washington, DC 20224. Do n

8453-EO to this address. Instead, see How 

page.

Instead of filing Form 8453-EO, an organization

officer filing an exempt organization’s return

through an electronic return originator (ERO) can

sign the return using a personal identification

number (PIN). For details, see Form 8879-EO, IRS e-file

Signature Authorization for an Exempt Organization.

● Authenticate the electronic Form 990, Return of

Organization Exempt From Income Tax, Form 990-EZ, Short

Form Return of Organization Exempt From Income Tax,

Form 990-PF, Return of Private Foundation, Form 1120-POL,

U.S. Income Tax Return for Certain Political Organizations,

or Form 8868, Application for Extension of Time To File an

Exempt Organization Return;

● Authorize the intermediate service provider (ISP) to

transmit via a third-party transmitter if you are filing online

(not using an ERO); and

Who Must File

If you are filing a 2004 Form 990, Form 990-EZ, Form

990-PF, Form 1120-POL, or Form 8868 with payment

through an ISP and/or transmitter and you are not using an

ERO, you must file Form 8453-EO with your electronically

filed return. An ERO can use either Form 8453-EO or Form

8879-EO to obtain authorization to file an organization’s

Form 990, Form 990-EZ, Form 990-PF, or 1120-POL, or to

file a Form 8868 with payment.

File Form 8453-EO with the organization’s electronically filed

return. Use a scanner to create a PDF file of the completed

form. Your tax preparation software will allow you to transmit

this PDF file with the return.

If the officer checks the box when filing Form 990-PF, Form

1120-POL, or Form 8868 with payment the officer must

ensure that the following information relating to the financial

institution account is provided in the tax preparation software.

● Routing number.

● Account number.

● Type of account (checking or savings).

● Debit amount.

● Debit date (date the organization wants th

occur).

● Form 8453-EO is signed by an organizatio

scanned into a PDF file, and transmitted wit

● The return is filed through an ERO and Fo

used to select a personal identification num

used to electronically sign the return.

The officer’s signature allows the IRS to d

ISP, ERO, and/or transmitter:

● An acknowledgment that the IRS has acc

organization’s electronically filed return,

● The reason(s) for a delay in processing th

refund, and

● If a refund offset may occur.

The declaration of officer must be signed 

● The president, vice president, treasurer, a

treasurer, chief accounting officer, or

● Any other organization officer authorized 

organization’s return.

Note. If the return is filed online through an 

transmitter (not using an ERO), do not comp

Use Only section in Part III.

If the organization’s return is filed through 

requires the ERO’s signature. A paid prepar

sign Form 8453-EO in the space for Paid P

Only. But if the paid preparer is also the ER

complete the paid preparer’s section. Instea

labeled “Check if also paid preparer.”

An electronically transmitted return will no

complete (and therefore not considered filed

TIP

Form 8868. Generally, file Form 8868 by the due date of

the return for which you are requesting an extension. The

Form 8453-EO must be filed with the electronically filed

Form 8868.