Declaration Control Number (DCN)

0 2 0 – – –

U.S. Individual Income Tax Declaration OMB No. 1545-1397 8453-OL for an IRS e-file On-Line Return

Form

Department of the Treasury

Internal Revenue Service

For the year January 1–December 31, 2001

 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.

Daytime phone number

( )

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

For Paperwork Reduction Act Notice, see back of form.

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). See instructions 5

Declaration of Taxpayer

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.

Sign

Here  Your signature Date

Part I

Cat. No. 15907C Form 8453-OL (2001)

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

Part II

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.

Under penalties of perjury, I declare that the information I have given my intermediate service provider and/or transmitter

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.

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

Important!

You must enter

your SSN(s) above.



6a

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

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

2001
Form 8453-OL (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 your box number only if the

post office does not deliver mail to your home.

Note: The address must match the address

shown on your electronically filed return.

Part II—Declaration of Taxpayer

● Routing number.

Line Instructions

Declaration Control Number (DCN). The

DCN is a 14-digit number assigned to your

return by your intermediate service provider

Refunds. Your refund should be issued within

3 weeks after the IRS has accepted your

return. However, some refunds may be

delayed because of compliance reviews to

ensure that returns are accurate. Refund

information is available on TeleTax. Call

1-800-829-4477.

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 you 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 your

apartment number. If you did not receive a

label, print or type the information in the

spaces provided.

When and Where To File

You must mail this form to the IRS on the

next working day after you have received

acknowledgment from your intermediate

service provider and/or transmitter that the

IRS has accepted your electronically filed

return. The address should be included in

your acknowledgment message. If not, mail

Form 8453-OL to the IRS at the applicable

address shown in the chart below. If you do

not receive an acknowledgement, you must

contact your intermediate service provider

and/or transmitter.

Purpose of Form

Use Form 8453-OL to:

Who Must File

If you are filing a 2001 Form 1040, 1040A, or

1040EZ through an intermediate service

provider and/or transmitter, you must file a

signed 2001 Form 8453-OL with the IRS. If

you do not, you will not have filed a valid

return for 2001, and we may not allow you to

file electronically next year.

You are not required to provide the

information requested on a form that is subject

to the Paperwork Reduction Act

The time needed to complete and file this

form will vary depending on individual

IF you live in . . . THEN mail Form 8453-OL to this address . . .

Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New

Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and all

APO and FPO addresses (except Asian/Pacific)

Illinois, Iowa, Kansas, Minnesota, Missouri, New Mexico, Oklahoma, Texas, Wisconsin

Florida, Indiana, Kentucky, Michigan, Ohio, South Carolina, West Virginia

Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, Tennessee

Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nebraska, Nevada, North

Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, and all Asian/Pacific APO and

FPO addresses

Receipt and Control Branch

Shipping and Receiving

310 Lowell Street

Andover, MA 05501

Receipt and Control Branch

Shipping and Receiving

P.O. Box 1231

Austin, TX 78767-1231

P.O. Box 1898

Attn: 8453-OL

Memphis, TN 38101

Stop 6052

1160 West 1200 South

Ogden, UT 84201

General Instructions

● Authenticate the electronic portion of your

2001 Form 1040, 1040A, or 1040EZ,

● Provide your 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.

Social Security Number (SSN). Be sure to

enter your SSN in the space provided on

Form 8453-OL. If a joint return, list the SSNs

in the same order as the first names.

Note: You must check all applicable boxes

on line 6.

● Account number.

● Type of account (checking or savings).

● Debit amount.

● Debit date (date you want the debit to

occur).

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 I—Tax Return Information

Line 5. Do not include any payment with

Form 8453-OL. The method of payment

depends on whether you check the box on

line 6b or 6c. For details, see the instructions

for Part II.

If you check box 6c, you must ensure that

the following information relating to the

financial institution account is provided in the

tax preparation software.

Your signature allows the IRS to disclose to

your intermediate service provider and/or

transmitter the reason(s) for a delay in

processing your return or refund. If you are

applying for a refund anticipation loan or

similar product, your signature also allows the

IRS to advise your intermediate service

provider and/or transmitter if a refund offset

may occur.

If there is an amount on line 5 and you

check box 6b and are paying by check or

money order, do not attach your payment to

Form 8453-OL. Instead, mail it by

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.

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.

● Send any accompanying paper schedules

or statements, and

Note: Do not send a copy of your

Form 1040, 1040A, or 1040EZ.

and/or transmitter. It should be included in

your acknowledgment message. Clearly type

or print the DCN in the top left corner of Form

8453-OL. The first two digits are always “00”.

The next six digits are the electronic filer

identification number (EFIN). The next five

digits are the batch number and serial

number. The “2” represents the year the

return is filed (2002).

April 15, 2002, with Form 1040-V to the IRS

at the applicable address shown on that form.

If you do not have a Form 1040-V, you may

be able to get it from your intermediate

service provider and/or transmitter. You can

also see your tax return instruction booklet for

other ways to get forms, or visit the IRS Web

Site at www.irs.gov.

You may be able to file a completely

paperless return! Your tax preparation

software contains information about

using a self-select PIN instead of filing Form

8453-OL. Or, you can visit the IRS Web Site

at www.irs.gov.

Stop 2701

Cincinnati, OH 45999