Declaration Control Number (DCN)

0 5 0 – – –

U.S. Individual Income Tax Declaration OMB No. 1545-0936 8453 for an IRS e-file Return Form

Department of the Treasury

Internal Revenue Service

For the year January 1–December 31, 2004

 See instructions on back.

Use the

IRS label.

Otherwise,

please

print or

type.

Daytime phone number

( )

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) 5

Declaration of Taxpayer (Sign only after Part I is completed.) Be sure to keep a copy of your tax return.

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 electronic return originator (ERO) 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.

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. 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 Authorized IRS e-file Providers. 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 Paid Preparer declaration is based on all information of which I have any knowledge.

Date Check ERO’s SSN or PTIN

if selfemployed

ERO’s ERO’s signature

Use

Only

Firm’s name (or

yours if self-employed),

address, and ZIP code

EIN

Phone no. ( )

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 Preparer’s SSN or PTIN

Preparer’s Paid signature

Preparer’s

Use Only

Firm’s name (or

yours if self-employed),

address, and ZIP code Phone no. ( )

Part I









 EIN

Cat. No. 62766T Form 8453 (2004)

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 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.

6a

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

Check if

also paid

preparer

b

Your first name and initial Last name Your social security number

L

A

B

E

L

H

E

R

E

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. Important!

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

You must enter

your SSN(s) above.



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

For Paperwork Reduction Act Notice, see back of form.

2004

Part II

Part III

Check

if selfemployed
Form 8453 (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 the box number only if the

post office does not deliver mail to the

taxpayer’s home.

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 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.

Part II—Declaration of Taxpayer

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. A Form 8453

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.

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 adjusted gross income on line 1 differs

from the amount on the electronic return by

more than $50, or

● The total tax on line 2, the federal income

tax withheld on line 3, the refund on line 4, or

the amount owed on line 5 differs from the

amount on the electronic return by more than

$14.

Part III—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:

The IRS requires the ERO’s signature. A paid

preparer must sign Form 8453 in the space

for Paid Preparer’s Use Only. 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.”

Boxes Entry

File identification number

(always “00”)

1–2

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:

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

Year digit (for returns filed in

2005, the year digit is “5”)

14

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 the taxpayer 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

apartment number. If the taxpayer did not

receive a label, print or type the information in

the spaces provided.

When and Where To File

This form must be mailed by the ERO to the

applicable submission processing center

within 3 business days after the ERO has

received acknowledgment from the IRS that

the return was accepted. See Pub. 1345A,

Filing Season Supplement for Authorized IRS

e-file Providers, for the address.

Use Form 8453 to:

● Authenticate the electronic portion of Form

1040, 1040A, or 1040EZ,

● Send any accompanying paper schedules

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

should not be attached),

● Authorize the electronic return originator

(ERO) to transmit via a third-party transmitter,

and

● Provide the taxpayer’s 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.

Purpose of Form

You are not required to provide the

information requested on a form that is

subject to the Paperwork Reduction Act

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.

Refunds. After the IRS has accepted the

return, the refund should be issued within 3

weeks. However, some refunds may be

delayed because of compliance reviews to

ensure that returns are accurate.

General Instructions

Note. If the paid preparer’s signature cannot

be obtained on Form 8453, you may attach a

copy of Form 1040, 1040A, or 1040EZ

instead. Attach only pages 1 and 2, and enter

“COPY—DO NOT PROCESS” on each page.

Social security number (SSN). Be sure to

enter the taxpayer’s SSN in the space

provided on Form 8453. If a joint return, list

the SSNs in the same order as the first

names.

Note. The taxpayer must check all applicable

boxes on line 6.

● Routing number.

● Account number.

● Type of account (checking or savings).

● Debit amount.

● Debit date (date the taxpayer wants the

debit to occur).

If there is an amount on line 5 and the

taxpayer checks box 6b and is paying by

check or money order, mail the payment by

April 15, 2005, with Form 1040-V to the

applicable address shown on that form.

Part I—Tax Return Information

Line 5. Do not include any payment with

Form 8453. The method of payment depends

on whether the taxpayer checks the box on

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

for Part II.

If the taxpayer checks box 6c, the taxpayer

must ensure that the following information

relating to the financial institution account is

provided in the tax preparation software.

Instead of filing Form 8453, the

taxpayer may be able to sign the

return electronically using a

self-selected personal identification number

(PIN). For details, go to the IRS website at

www.irs.gov or see Pub. 1345.

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

My Refund.

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

information and follow the recorded

instructions.

● Call 1-800-829-1954.

TIP

Form 8453 may be faxed between the

taxpayer and the ERO. The ERO must receive

the faxed signed Form 8453 prior to

transmitting the return to the IRS. The

completed Form 8453, with signatures, must

be mailed to the IRS.