Declaration Control Number (DCN)

8453 U.S. Individual Income Tax Declaration OMB No. 1545-0938
Fe . tt $$___
orm for Electronic Filing
Department ofthe Treasury For the year January 1-December 31, 1991 1991
Internal Revenue Service > See instructions on back.
L / Your first name and initial Last name ~\ Your social security number
th A : ‘
ye label. 8 if a joint return, spouse's first name and initial Last name Spouse's social security number
Otherwise, | L : :
please 4 Home address (number and street). (If a P.O. box, see instructions.) Apt. no. Telephone number (optional)
rint or
type. E ( )
i City, town or post office, state, and ZIP code For Paperwork Reduction Act
Notice, see instructions.

If the taxpayer’s name changed during the past 3 years due to marriage, divorce, etc., and he or she filed a Federal income tax
return for such years using the former name, enter the most recently used last name here. >
Tax Return Information (Whole dollars only)

1 Total income (Form 1040, line 23; Form 1040A, line 14; Form 1040EZ, line 3). . . 2. 1... 1
2 Total tax (Form 1040, line 53; Form 1040A, line 27; Form 1040EZ, line 7) . . . 2
3 Federal income tax withheld (Form 1040, line 54; Form 1040A, line 28a; Form 1040€Z, ‘line 6). it

any is from Form(s) 1099, check here ® LC]. . coe ee ee 3
4 Refund (Form 1040, line 62; Form 1040A, line 30; Form 1040EZ, line 8. rs 4
5 Amount you owe (Form 1040, line 64; Form 1040A, line 32; Form 1040EZ, line ‘9 rr 5

Direct Deposit of Refund (See instructions.)
6 Name of financial institution and, if applicable, branch name

The first two numbers of the RTN must
7 Routing transit number (RTN) be 01 through 12 or 21 through 32.

1099-R here.

8 Depositor account number (DAN)
9 Type of depositor account: [] Savings 1 Checking 10 Proof of account: [1 Check [1 Other
11 Ownership of deposit account: [1 Self [1] Spouse O Self and Spouse

Declaration of Taxpayer

Under penalties of perjury, I declare that | have compared the information contained on my return with the information | have provided to my electronic return originator (ERO) and
that the amounts described in Part | above agree with the amounts shown on the corresponding lines of my 1991 Federal income tax return. To the best of my knowledge and
belief, my return is true, correct, and complete. | consent that my retum, including this declaration and accompanying schedules and statements, be sent to the IRS by my ERO.
Hf I have elected Direct Deposit, | declare that the information shown on lines 6 through 11 in Part fl above is correct; | consent that my refund be directly deposited as
designated in Part Il above; and | authorize the IRS to i my ERO and/or the my request for Direct Deposit will be honored. If this retum is a
joint return and the refund is to be directly deposited, this is an irrevocable appointment of the other spouse as an agent to receive the refund. if | have filed a balance due return
and/or elected to make an ADEPT payment, | 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. if | have filed a joint Federal and state tax return, | understand that if there is an error on my state return my Federal return will be rejected,

Forms W-2, W-2G, and

Attach Copy B of your

Please

Sign

Here Your signature Date ‘Spouse's signature (if joint return, BOTH must sign) Date
Declaration of Electronic Return Originator (ERO) and Paid Preparer (See instructions.)

| declare that | have reviewed the above taxpayer's return and that the entries on Form 8453 are complete and correct to the best of my knowledge. (EROs who are collectors are
not responsible for reviewing the taxpayer's return; however, they must ensure that Form 8453 accurately reflects the data on the return.) If Part Il is completed, | deciare that |
have verified the taxpayer's proof of account and that this proof of account agrees with the name shown on this declaration. | have obtained the taxpayer's signature on Form
8453 before submitting this return to the IRS, have provided the taxpayer with a copy of all forms and information to be filed with the IRS, and have followed all other
requirements described in Pub. 1345, Handbook for Electronic Filers of Individual Income Tax Returns (Tax Year 1991). If | am also the Paid Preparer, under penalties of perjury |
dectare that | 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, Declaration of preparer 1s based on all information of which the preparer has any knowledge.

Date Cheek if Check Your social security number
+, ERO's also paid if self-
ERO’s signature preparer LC] | employes 1) too:
Use = Fims ame (or E.l. No. :
ours i set employ
Only  ousausesenore ZIP code

Under penalties of perjury, | deciare that | have examined the above taxpayer's retum and accompanying schedules and statements, and to the best of my knowledge and belief,
they are true, correct, and complete. Declaration of preparer 1s based on ail information of which the preparer has any knowledge.

Date Check Preparer's social security no.
‘ Preparer's if self-
Paid signature > employed C]
Preparer’s Firm's name (or El No.
Use Only Yu's; sett-empioyed)
Vand address ZIP code

Cat. No. 62766T


Form 8453 (1991)

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 more simple, we would
be happy to hear from you, You can write to
both the Internal Revenue Service,
Washington, DC 20224, Attention: IRS
Reports Clearance Officer, T:FP; and the
Office of Management and Budget,
Paperwork Reduction Project (1545-0936),
Washington, DC 20503. DO NOT send this
form to either of these offices.

Changes You Should Note

© For tax year 1991, the Austin Service
Center will accept returns from approved
electronic return originators (EROs) in Kansas,
New Mexico, Oklahoma, and Texas. (These
states were previously serviced by the Ogden
Service Center.) The Memphis Service Center
will accept returns from approved EROs in
Alabama, Arkansas, Florida, Georgia,
Louisiana, Mississippi, North Carolina, and
Tennessee. (These states were previously
serviced by the Cincinnati Service Center.)

© Also, for tax year 1991 the Austin and
Memphis Service Centers, in addition to the
Cincinnati and Ogden Service Centers, will
accept electronically filed balance due returns
from approved EROs.

Additional Information

Get Pub. 1345, Handbook for Electronic
Filers of Individual Income Tax Returns (Tax
Year 1991), for more details, including
step-by-step mailing instructions and
addresses for each of the service centers that
accept electronic returns.

Line Instructions

Declaration Control Number (DCN). The
DCN is a 14-digit number assigned by the
ERO to each taxpayer's return. The ERO
should enter this number only after the IRS.
has acknowledged receipt of the electronic
Portion of the return. The number should be
entered as follows:

Boxes Entry

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

3-8 Electronic filer identification
number (EFIN) assigned by the
IRS

O11 Batch number (000 to 999)
assigned by the ERO

12-13 Serial number (00 to 99)
assigned by the ERO

14 Year digit (for 1992, the year

digit is “2”)
Example. The EFIN is 509325. The batch
number is 000. The serial number is 56. The
DCN should be 00-509325-00056-2.

Name, Address, and Social Security
Number. If the taxpayer received a mailing

label from the IRS, place the label in the
name area. Cross out any errors and print the
correct information on the label. 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.
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 P.O. box number
instead of the address.

Note: The address must match the address
shown on the electronically filed Form 1040,
Form 1040A, or Form 1040EZ.

Part I—Tax Return Information
Line 3. Include any withholding from Form(s)
1099 in the amount you enter on line 3. Also
be sure to check the box on line 3.

Line 5. For balance due returns, do not
attach the check or money order to Form
8453. Instead, mail it with Form 9282 to the
address shown on that form.

If payment is made using the Automated
Deposit of Electronic Payments for Taxes
(ADEPT) system, please write “ADEPT” in the
top margin above the title of Form 8453.
Note: ADEPT is a test system offered only to
certain approved filers that send electronic
returns to the Andover Service Center.

Part II—Direct Deposit of Refund
Taxpayers can elect to have their refund
directly deposited by completing Part Il.

Line 7. The routing transit number (RTN) must
contain nine digits. If the RTN does not begin
with 01 through 12, or 21 through 32, the
Direct Deposit request will be rejected.

Line 8. The depositor account number (DAN)
can contain 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 10. To be eligible for Direct Deposit,
taxpayers must provide proof of account
ownership to their ERO. An acceptable proof
of account ownership is a check, form,
report, or other statement generated by the
financial institution that has the taxpayer's
name, RTN of the financial institution, and the
depositor account number preprinted on it.

For accounts that are 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
account number 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).
Note: Some financial institutions may not
accept Direct Deposits into accounts that are
payable through another bank or financial
institution, including credit unions.

Line 11. The account designated to receive
the Direct Deposit must be in the taxpayer's
name. If the taxpayer's 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 it
can be a joint account in both spouses’
names.

Note: The account cannot include the name
of any other person unless the taxpayer's
filing status on the return is married filing
jointly or married filing separately, and the
taxpayer's spouse is the other name listed on
the account.

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.

Part III—Declaration of Taxpayer
An electronically transmitted income tax
return will not be considered complete, and
therefore, filed, unless and until a Form 8453
signed by the taxpayer is received by the IRS.

The taxpayer's signature is required for all
returns. If Part Il is completed, this signature
allows the IRS to advise the ERO and/or the
transmitter if a Direct Deposit election will not
be honored.

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:
© 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.

Part IV—Declaration of Electronic
Return Originator (ERO) and Paid
Preparer

The ERO’s signature is required by the IRS.

A paid preparer must sign Form 8453 in the
space for Paid Preparer’s Use Only. Only
handwritten signatures are acceptable.
However, 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.”

Refunds. After the IRS has accepted the
retum, the refund should be issued within 3
weeks. If the taxpayer elects to have the
refund directly deposited into a savings or
checking account, the taxpayer's account
may be credited even sooner.

Automated Refund Information. Refund
information is available on Tele-Tax. See the
instruction booklet for Form 1040, 1040A, or
1040E2Z, for a list of Tele-Tax information
telephone numbers. Tele-Tax will have refund
information 3 weeks after the IRS has
acknowledged receipt of the return.

If 4 weeks have passed and Tele-Tax
doesn't have information about the refund,
the taxpayer can call the telephone
assistance number listed in the instruction
booklet for Form 1040, 1040A, or 1040EZ.
Taxpayers will need to know the DCN and the
acknowledgment date of their electronic
return before calling for assistance.