Form XXXXXX Authorized Cyber Assistant Host Application

Complete Form XXXX to apply to become a Cyber Assistant Host. To become a Cyber Assistant Host you must complete this application and satisfy the criteria set forth in Revenue Procedure 2009-XX.

PLEASE COMPLETE THE ENTIRE APPLICATION

PART I – GENERAL INFORMATION

Check the box that describes your business.
	Sole Proprietorship		Partnership				Corporation
	Other – describe
Enter your taxpayer identification number or employer identification number
Enter the legal name of your business as shown on its tax return
Enter any other name your business goes by (doing business as (DBA) name)
Enter the address where your business is located:
	Street Address			City				State		Zip Code
Enter your business phone number including area code
Enter your mailing address if different from your business location:
	Street Address or P.O. Box			City				State		Zip Code
Enter the name, title, address and telephone number of the primary person to contact:
	Full Name and Title of Primary Contact Person							Telephone Number
	Street Address or P.O. Box			City				State		Zip Code
Enter the name, title, address and telephone number of an alternate person to contact:
	Full Name and Title of Alternate Contact Person							Telephone Number
	Street Address or P.O. Box			City				State		Zip Code

PART II – INFORMATION ABOUT PRINCIPAL OFFICER(S)

5. In the table below, enter the name, title, social security number (SSN), date of birth and home address of the principal officer(s) of the business. If the business is a:

• Sole Proprietorship – enter your name, title, etc.

• Partnership – enter the information for each partner who has a five percent (5%) or more interest in the partnership. If no partners have a 5% or more interest, enter the information for at least one individual authorized to act for the business in legal or tax matters.

• Corporation – enter the information for the top management official and the top financial official of the corporation.

In addition, answer questions 10(f) and 10(g) for each principal identified in 10(a). Attach a continuation sheet if you need more space.

	Name (Last, First, Middle)	Title	SSN	Date of Birth
	Home Address (Street Address or P.O., City, State and Zip Code)

10. For each individual identified in 10(a) above, check the box next to the descriptions that apply and provide the following information:

• If an enrolled agent (EA), enter the individual’s enrolled agent number in the space provided.

• If an authorized e-File provider, enter the ETIN or EFIN number in the space provided.

• If an attorney, attach proof, such as a State Bar Card, that shows that the individual is in good standing with the highest court in any state, commonwealth, possession, territory, or the District of Columbia.

• If a CPA, attach a copy of the individual’s license to practice as a CPA in any state, commonwealth, possession, territory, or the District of Columbia.

Be sure to check all that apply. Attach a continuation sheet if you need more space.

	Attorney	CPA	EA		Authorized e-File Provider
	Attorney	CPA	EA		Authorized e-File Provider
	Attorney	CPA	EA		Authorized e-File Provider
	Attorney	CPA	EA		Authorized e-File Provider
	Attorney	CPA	EA		Authorized e-File Provider

10(g) Has the applicant organization or any of its principals listed in 10(a), above, ever been assessed any preparer penalties, been indicted or convicted of a crime, failed to timely and accurately file tax returns, or failed to timely pay tax liabilities? Yes No

If yes, attach an explanation, including the identity the listed principal(s) involved.

PART III – APPLICANT’S AGREEMENT

Please review the following statement and if you agree with the terms sign and date the statement.

Under penalties of perjury, I declare that I have examined this application and read all accompanying information, and to the best of my knowledge and belief the information provided is true, correct and complete. If accepted as an authorized Cyber Assistant Host, the business and its employees will comply with all provisions of Revenue Procedure 2009-XX, governing participation in the program, and any related publication for the entirety of our participation. Acceptance is not transferable. I understand that a new application must be filed if the business is sold or its organizational structure changes. I further understand that noncompliance with the rules governing participation in the Cyber Assistant Program will result in the business or individuals listed on this application being suspended from participation in the program and may result in other sanctions as explained in Revenue Procedure 2009-XX.

I am authorized to make and sign this statement on behalf of the business and individuals listed on this application.

Print full name (Last, First, Middle)		Title
Sign Here►
			Date

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. We need it to ensure that you are complying with these laws.

The IRS may not conduct or sponsor data gathering efforts, and 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 collection of information must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103.

Form XXXXX

Page 0 of 4

Catalog Number XXXXXX

Department of the Treasury─­­ Internal Revenue Service