Declaration Control Number (DCN)

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g 8453-0L U.S. Individual Income Tax Declaration OME No, 1545-1997
* for On-Line Service Electronic Filing
partment of he Treasury For the year January 1-December 31, 1995 1995
Internal Revenue Service > See instructions on back.
| You" fist name and initia Last name ~) Your social security number
A H H
Use fhe 8 If a joint return, spouse's first name and initial Last name ; security number
Otherwise, | L H
please H Home address (number and street). If a P.O. box, see instructions. Apt. no. Telephone number (optional)
print or
type. E ( )
City, town or post office, state, and ZIP code For Paperwork Reduction Act
E Notice, see instructions.
Part Tax Return Information (Whole dollars only)
1 Total income (Form 1040, line 22; Form 1040A, line 14; Form 1040EZ, line 4). . . . 2... 1
2 Total tax (Form 1040, line 54; Form 1040A, line 28; Form 1040EZ, line 10). . . . 2

3 Federal income tax withheld (Form 1040, line 55; Form 1040A, line 29a; Form 1040EZ, line 7). If

any is from Form(s) 1099, check here > 3

4 Refund (Form 1040, line 63; Form 1040A, line 31; Form 1040EZ, line 11) . 2. . 2... ee 4
5 Amount you owe (Form 1040, line 65; Form 1040A, line 33; Form 1040EZ, line 12)... 5
Part Il Direct Deposit of Refund (Optional—See instructions.)

g g | 6 Name of financial institution and, if applicable, branch name P ....

fe |

5, The first two numbers of the RTN must

38 | 7 Routing transit number (RTN) be 01 through 12 or 21 through 32.

oy

oe

Ba |

8& | 8 Depositor account number (DAN)

$= |

#3 | 9 Type of account: 01 Checking 0 Savings

<3 |

|10 Ownership of account: C1 Self C) Spouse O Self and Spouse

rt I Declaration of Taxpayer

If | have completed Part Il above, | consent that my refund be directly deposited as designated in Part Il, and declare that the
information on lines 6 through 10 is correct. If | have filed a joint return, this is an irrevocable appointment of the other spouse as
an agent to receive the refund.

If | have filed a balance due return, | understand that if the IRS does not receive full and timely payment of my tax liability, | will
remain liable for the tax liability and all applicable interest and penalties.

Under penalties of perjury, | declare that the information | have given my on-line service provider (OLSP) or transmitter and the
amounts in Part | above agree with the amounts on the corresponding lines of the electronic portion of my 1995 Federal income
tax return. To the best of my knowledge and belief, my return is true, correct, and complete. | consent that the electronic portion
of my return be sent to the IRS by my OLSP or transmitter. | also consent to the IRS sending to my OLSP or transmitter an
acknowledgment of receipt of transmission and an indication of whether or not my return is accepted and, if rejected, the reason(s)
for the rejection.

Sign |
Here P Your signature Date Spouse's signature, Ifa joint return, BOTH must sign. Date
Cat. No. 159076 Form 8453-OL (1995)



Form 8453-OL (1995)

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.

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 below.

Purpose of Form
Use Form 8453-OL to:

Authenticate the electronic portion of
Form 1040, 1040A, or 1040EZ,

@ Send any accompanying paper
schedules and statements, and

@ Request that we directly deposit any
refund into your bank account.

Who Must File

If you are filing a 1995 Form 1040,
1040A, or 1040EZ through an on-line
service provider (OLSP) or transmitter,
you must file a signed 1995 Form
8453-OL.

When and Where To File

You must mail this form to your OLSP or
transmitter on the next working day after
you have received acknowledgment from
your OLSP or transmitter that the IRS
has accepted your electronically filed
return. The address should be included
in your acknowledgment message.

Line Instructions

Declaration Control Number (DCN).
The DCN is a 14-digit number assigned
to your return by your OLSP or
transmitter. It is included in your
acknowledgment message. Clearly type
or print the DCN in the top left corner of
Form 8453-OL. The number should be in
the following format:

Boxes Entry

1-2 File identification number
(always “00”)

3-8 Electronic filer identification
number (EFIN) assigned to:
your OLSP or transmitter by
the IRS

9-11 Batch number (000 to 999)
assigned by your OLSP or
transmitter

12-13 Serial number (00 to 99)

assigned by your OLSP or
transmitter
14 Year digit (for returns filed in
1996, the year digit is “6”)
Example. The EFIN is 509325. The
batch number is 000. The serial number
is 56. The DCN is 00-509325-00056-6.

Name, Address, and Social Security
Number (SSN). If you received a
peel-off label from the IRS, place it in
the name area. Cross out any errors and
print the correct information. Add any
missing items, such as apartment
number. If you did not receive a label,
print or type the information in the
spaces provided. Make sure your SSN is
clear and correct. An incorrect or
missing SSN may delay any refund. If a
joint return, be sure the names and
SSNs are listed in the same order.

P.O. Box. If the post office does not
deliver mail to your home and you have
a PO. box, enter the box number.

Note: The address must match the
address shown on your electronically
filed return.

Part I—Tax Return Information

Line 3. If you have any withholding from
Form(s) 1099, include it in the amount
you enter on line 3 and check the box.

Line 5. Do not attach your check or
money order to Form 8453-OL. Instead,
mail it by April 15, 1996, with Form
1040-V, Payment Voucher, to the Internal
Revenue Service, P.O. Box 970016, St.
Louis, MO 63197-0016. You may have
received a Form 1040-V with your tax
package. If not, you may be able to get
Form 1040-V from your OLSP or
transmitter or you can call the IRS at
1-800-TAX-FORM (1-800-829-3676).

Part II—Direct Deposit of Refund

Complete this part if you choose to have
your refund directly deposited. Your
routing transit number (RTN) and
depositor account number (DAN) may be
shown on the bottom left of your check.
For accounts payable through a
financial institution other than the one at
which the account is located, you must
enter the RTN of the bank or institution
where the account is located. You may
find this information on your account
statement_or account identification card.
Printed on recycled paper

\f you have any doubt about the
correct RTN, contact your financial
institution and ask for the correct RTN
for direct deposit (Electronic Funds
Transfers).

Note: Some financial institutions may not
accept direct deposits into accounts that
are payable through another bank or
financial institution, including credit
unions.

Line 7. The RTN must be nine digits. If it
does not begin with 01 through 12 or 21
through 32, your direct deposit will be
rejected and a check sent.

Line 8. The DAN can be up to 17
characters (both numbers and letters).
Include hyphens but omit spaces and
special symbols. If fewer than 17
characters, enter the number from left to
right and leave the unused boxes blank.

Line 10. The account designated to
receive the direct deposit must be in
your name. If you are married filing
jointly, the account can be in either
name or both your names. If you are
married filing separately, the account
can be in your name or in both your
name and your spouse’s name.
Caution: The account cannot include
the name of any other person except as
noted above.

Some financial institutions will not
allow a joint refund to be deposited into
an individual account. The IRS is not
responsible when a financial institution
refuses a direct deposit for this reason.

Part IIl—Declaration of Taxpayer

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.

Refunds. Your refund should be issued
within 21 days after the IRS has
accepted your return. However, some
refunds may be delayed because of
compliance reviews to ensure that
returns are accurate.

Automated Refund Information.
Refund information is available on
Tele-Tax. If you live in Kansas, New
Mexico, Oklahoma, or Texas, you may
call 1-800-829-4477. If you don’t live in
one of these states, you may call either
214-767-1792 or 713-541-3400. These
are not toll-free calls. If your refund is
delayed or you don’t get complete
information from Tele-Tax, you may call
the Austin Service Center at
512-462-8900 (Ext. 7197). This is not a
toll-free call.

“U.S. Government Printing Office: 1995 - 405-493/20216