Declaration Control Number (DCN)

0 6 0 – – –

U.S. Individual Income Tax Declaration OMB No. 1545-0936 8453 for Electronic Filing Form

Department of the Treasury

Internal Revenue Service

For the year January 1–December 31, 1995

© 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. Telephone number (optional)

( )

City, town or post office, state, and ZIP code For Paperwork Reduction Act

Notice, see instructions.

Tax Return Information (Whole dollars only)

1 Total income (Form 1040, line 22; Form 1040A, line 14; Form 1040EZ, line 4) 1

2 Total tax (Form 1040, line 54; Form 1040A, line 28; Form 1040EZ, line 10) 2

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

3

4 Refund (Form 1040, line 63; Form 1040A, line 31; Form 1040EZ, line 11) 4

5 Amount you owe (Form 1040, line 65; Form 1040A, line 33; Form 1040EZ, line 12) 5

Direct Deposit of Refund (Optional—See instructions.)

6 Name of financial institution and, if applicable, branch name ©

7 Routing transit number (RTN)

The first two numbers of the RTN must

be 01 through 12 or 21 through 32.

8 Depositor account number (DAN)

10 Ownership of account:

Attach Copy B of

Forms W-2, W-2G,

and 1099-R here.

Self Spouse Self and Spouse

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 1995 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, and, if rejected, the reason(s)

for the rejection.

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. If Part II is completed,

I declare that I have verified the taxpayer’s proof of account and it agrees with the name shown on this form. 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 Electronic Filers of Individual Income Tax Returns (Tax Year 1995). 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 declaration is based on all information of which I have any knowledge.

Date Check Your social security number

if selfemployed

ERO’s

ERO’s signature

Use

Only

Firm’s name (or yours

if self-employed)

and address

EIN

ZIP code

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 social security no.

if selfemployed

Preparer’s Paid signature

Preparer’s

Use Only

Firm’s name (or yours

if self-employed)

and address ZIP code

Part III

Part II

Part I

Part IV

©

©

©

©

© EIN

Cat. No. 62766T Form 8453 (1995)

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 Part II, and declare that the information shown on lines 6 through 10 is correct.

If I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to receive the refund.

11

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

Check if

also paid

preparer

9 Type of account: Checking Savings
Form 8453 (1995) Page 2

Caution: The account cannot include the

name of any other person except as noted

above.

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.—If the post office does not

deliver mail to the taxpayer’s home and the

taxpayer has a P.O. box, enter the box

number.

Some financial institutions do not permit

the deposit of a joint refund into an

individual account. The IRS is not

responsible when a financial institution

refuses a direct deposit for this reason.

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

below. Part I—Tax Return Information

Part III—Declaration of Taxpayer

Line 5.—Do not include the payment with

Form 8453. Instead, mail it by April 15,

1996, with Form 1040-V, Payment

Voucher, to the address shown on that

form.

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, the ERO must have the

taxpayer complete and sign a corrected

Form 8453 if either of the following applies:

Part II—Direct Deposit of Refund

Taxpayers can elect to have their refund

directly deposited by completing Part II.

But to do so, they must provide proof of

account ownership to their ERO.

Acceptable proof is a check, form, report,

or other statement generated by the

financial institution with the routing transit

number (RTN), taxpayer’s name, and

depositor account number (DAN) printed

on it.

Line 7.—The RTN must be nine digits. If it

does not begin with 01 through 12 or 21

through 32, the direct deposit will be

rejected.

● The total income on line 1 differs from

the amount on the electronic return by

more than $25, or

● The total tax on line 2, the refund on line

4, or the amount owed on line 5 differs

from the amount on the electronic return

by more than $7.

Line 8.—The DAN can be up to 17

alphanumeric characters. 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 3.—If the taxpayer had any

withholding from Form(s) 1099, include it in

the amount you enter on line 3 and check

the box.

Part IV—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:

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.”

For accounts payable through a financial

institution other than the one at which the

account is located, the taxpayer must

provide a document, such as an account

statement or account identification card,

showing the RTN of the bank or institution

where the account is located. A deposit

slip should not be used to verify the RTN

and DAN because it can contain internal

routing numbers that are not part of the

RTN. If there is any doubt about the

correct RTN, the taxpayer should contact

the financial institution and ask for the

correct RTN for direct deposit (Electronic

Funds Transfers).

Refunds.—After the IRS has accepted the

return, the refund should be issued within

21 days. However, some refunds may be

temporarily delayed because of compliance

reviews to ensure that returns are

accurate.

Boxes Entry

File identification number

(always “00”)

1–2

Automated Refund Information.—Refund

information is available on Tele-Tax. See

the instruction booklet for Form 1040,

1040A, or 1040EZ for the telephone

number.

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

Note: Some financial institutions may not

accept direct deposits into accounts that

are payable through another bank or

financial institution, including credit unions.

Year digit (for returns filed in

1996, the year digit is “6”)

14

Line 10.—The account designated to

receive the direct deposit must be in the

taxpayer’s name. If the filing status on the

return is married filing jointly, the account

can be in either or both spouses’ names. If

the filing status is married filing separately,

the account can be in the taxpayer’s name

or in both spouses’ names.

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 the taxpayer received a

peel-off label from the IRS, place the label

in the name area. Cross out any errors and

print the correct information. Add any

missing items, such as apartment number.

If the taxpayer did not receive a label, print

or type the information in the spaces

provided. Please verify that the 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.

When and Where To File

This form must be mailed to the service

center where the electronic return was

transmitted on the next working day after

the ERO has received acknowledgment

from the IRS that the return was accepted.

Only the Andover, Austin, Cincinnati,

Memphis, and Ogden Service Centers can

accept electronic returns. Get Pub. 1345,

Handbook for Electronic Filers of Individual

Income Tax Returns (Tax Year 1995). It has

step-by-step mailing instructions and

addresses for the service centers.

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 overpayment.

Purpose of Form

Printed on recycled paper

Note: If the taxpayer wants the refund

directly deposited, be sure the

corresponding box for line 11 in Part III is

checked.

The IRS requires the ERO’s signature.

All filers must check one of the boxes

for line 11.