Declaration Control Number (DCN)

0 5 0 – – –

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

Department of the Treasury

Internal Revenue Service

For the year January 1–December 31, 2004

 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 you have 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 37; Form 1040A, line 22; Form 1040EZ, line 4) 1

2 Total tax (Form 1040, line 62; Form 1040A, line 38; Form 1040EZ, line 10) 2

3 Federal income tax withheld (Form 1040, line 63; Form 1040A, line 39; Form 1040EZ, line 7) 3

4 Refund (Form 1040, line 72a; Form 1040A, line 45a; Form 1040EZ, line 11a) 4

5 Amount you owe (Form 1040, line 74; Form 1040A, line 47; Form 1040EZ, line 12) (see instructions) 5

Declaration of Taxpayer. Be sure to keep a copy of your tax return.

I consent that my refund be directly deposited as designated in the electronic portion of my 2004 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

Cat. No. 15907C Form 8453-OL (2004)

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 I have examined a copy of my electronic individual income tax return and

accompanying schedules and statements for the tax year ending December 31, 2004, and to the best of my knowledge and

belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts shown on the

copy of my electronic income tax return. I consent to allow my intermediate service provider and/or transmitter to send my

return to the IRS and to receive from the IRS (a) an acknowledgment of receipt or reason for rejection of the transmission,

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

refund.

 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 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

2004

Part I Form
Form 8453-OL (2004) 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

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 “5” represents the year the

return is filed (2005).

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.

Example. The EFIN is 509325. The batch

number is 000. The serial number is 56. The

DCN is 00-509325-00056-5.

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 incorrect information 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 acknowledgment, you must

contact your intermediate service provider

and/or transmitter.

Printed on recycled paper

Who Must File

If you are filing a 2004 Form 1040, 1040A, or

1040EZ through an intermediate service

provider and/or transmitter and you do not

use a self-select PIN, you must file a signed

2004 Form 8453-OL with the IRS.

You are not required to provide the

information requested on a form that is subject

to the Paperwork Reduction Act unless the form

The time needed to complete and file this

form will vary depending on individual

circumstances. The estimated average time is

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

Connecticut, Delaware, District of Columbia, Florida, Indiana, Kentucky, Maine, Maryland,

Massachusetts, Michigan, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode

Island, South Carolina, Vermont, Virginia, West Virginia, all APO and FPO addresses (except

Asian/Pacific)

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Georgia, Hawaii, Idaho, Illinois,

Iowa, Kansas, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New

Mexico, North Carolina, North Dakota, Oklahoma, Oregon, South Dakota, Tennessee, Texas,

Utah, Washington, Wisconsin, Wyoming, all Asian/Pacific APO and FPO addresses, a foreign

country: U.S. citizens and those filing Form 2555 or Form 2555-EZ

Internal Revenue Service

Attn: Shipping and Receiving, 0254

Receipt and Control Operations

Andover, MA 05544-0254

Internal Revenue Service

Attn: Shipping and Receiving, 0254

Receipt and Control Branch

Austin, TX 73344-0254

General Instructions

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. A Form 8453-OL

signed by an agent must have a power of

attorney attached that specifically authorizes

the agent to sign the return. To do this, you

can use Form 2848, Power of Attorney and

Declaration of Representative.

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.

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

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.

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 Internal

Revenue Service, Tax Products Coordinating

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

Constitution Ave. NW, Washington, DC 20224.

Do not send the form to this address. Instead,

see When and Where To File on this page.

Note. Do not mail a copy of your Form 1040,

1040A, or 1040EZ.

You may be able to file a completely

paperless return! Your tax preparation

software should contain information

about using a self-select personal

identification number (PIN) instead of filing

Form 8453-OL. Or, you can go to the IRS

website at www.irs.gov.

Purpose of Form

Use Form 8453-OL to:

● Authenticate the electronic portion of your

2004 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.

● Send any accompanying paper schedules

or statements (Forms W-2, W-2G, or 1099-R

should not be attached), and

Refund information. You can check on the

status of your 2004 refund if it has been at

least 3 weeks from the date you filed your

return. To check on the status of your 2004

refund, do one of the following:

● Go to www.irs.gov and click on Where’s

My Refund.

● Call 1-800-829-1954.

● Call 1-800-829-4477 for automated refund

information and follow the recorded

instructions.

Form 8453-OL. Instead, mail it by April 15,

2005, 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 go to the IRS website at

www.irs.gov.

TIP