Form 14234 Pre-CAP/CAP Application Form

Department of the Treasury — Internal Revenue Service

Form 14234
(April 2011)

OMB No. 1545-1800

Pre-CAP and CAP Application Form

Taxpayer Name per Tax Return

EIN
Check if Applying for
Pre-CAP
Fiscal Year Ending

Address per Tax Return

CAP

Yes
1.

No

Did the taxpayer report total assets on the prior U.S. income tax return equal to or
exceeding $10,000,000?

2a. Is the taxpayer publicly-held with a legal requirement to prepare and submit Forms
10K, 10Q, 8K, or 20F or other disclosure type forms to the SEC or equivalent
regulatory body?
2b. If no in 2a, does the taxpayer prepare certified, audited financial statements or
equivalent documentation on a quarterly basis?
3.

Is the taxpayer currently under examination by the Internal Revenue Service (IRS)?

4.

Is the taxpayer currently in litigation or under investigation by the IRS or any Federal
or State agency which would limit access to the current corporate tax records or the
investigation could result in a material tax item? If yes, provide a brief explanation in
line 7 below.
Has the taxpayer entered into any listed transaction as defined in the Instructions to
Form 8886, Reportable Transaction Disclosure Statement, for any open tax year or
filed year under examination or in Appeals? If yes, please attach a copy of Form
8886.
Did the taxpayer recently undergo any changes that would affect the taxpayer's ability
to dedicate resources to the CAP program or limit the availability of records?

5.

6.
7.

If necessary, provide brief explanation described in Line 4.

Signature of Authorized Officer:
Name:

Title:

Phone Number:

E-Mail:

Catalog Number. 57607D

www.irs.gov

Form 14234 (4-2011)

Paperwork Reduction Act Notice.
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 section 6103.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated burden for
taxpayers who file this form is 1 hour and 52 minutes.
If you have comments concerning the accuracy of these time estimates 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, IR-6526, Washington, DC 20224. Do not send the form to this
address.

Form 14234 (4-2011)