IRS Tax Check Waiver

IRS Tax Check Waiver

Name: ________________________________________________

OCC Application Number: __________________________

TAX CHECK WAIVER

I am signing this waiver to permit the Internal Revenue Service (IRS) to release information about me which would otherwise be confidential. This waiver is made pursuant to 26 USC 6103(c).

I designate that the Internal Revenue Service release return and return information to:

(Insert Name)

(Insert Title)

Office of the Comptroller of the Currency

(Insert Address)

Check One:

Have I failed to timely file a federal income tax return by the required due date (determined with regard to any extension of time for filing) for any of the last three years for which the filing of a return might have been required? (NOTE - If the filing date [without regard to extensions] and normal processing period for the most recent year’s return has not yet elapsed on the date IRS receives this waiver, and the IRS records do not indicate a return for the most recent year, the “last three years” will mean the three years preceding the year for which returns are currently being filed and processed.)	□ Yes	□ No
Have I failed to pay any tax, penalty, or interest liability during the current or last three calendar years within 10 days of the date on which the IRS gave notice of the amount due and requested payment?	□ Yes	□ No
3. Am I now or have I ever been under investigation for a misdemeanor or possible criminal offenses?	□ Yes	□ No
4. Has any civil penalty for fraud been assessed against me during the current or last three calendar years?	□ Yes	□ No
If a return for any of the last three years was not filed, explain why. If there was insufficient income to meet filing requirements or filing requirements were met by filing with a foreign tax agency (for example, Puerto Rico or the Virgin Islands), describe the circumstances).

To help the IRS find my tax records, I am voluntarily giving the following information:

Name (print or type):

Social Security Number (SSN):

Current Home Address: _________________________________________________

_______________________________________________________________________

Telephone Numbers: (Home) (Work)

(Area Code) (Area Code)

Names and addresses shown on last three years’ returns (if different from above).

Year Name Address

I authorize the IRS to release any additional relevant information necessary to respond to the questions above.

Signature: _________ Date: _________________________

(Signature of taxpayer authorizing the disclosure of (This consent is valid only if received by the

Confidential tax information) IRS within 120 days of this date.)

Original signed signature and signed date is required

If married and filing a joint return:

Spouse’s Name Spouse SSN:

Signature: _________ Date: _________________________

(Signature of taxpayer authorizing the disclosure of (This consent is valid only if received by the

Confidential tax information) IRS within 120 days of this date.)

Original signed signature and signed date is required

Your social security number (and that of your spouse when joint returns have been filed) is requested to allow the Comptroller of the Currency to determine whether your Federal tax obligations have been fulfilled as part of its consideration of your suitability for a position as shareholder, officer, director, employee, or agent of a national bank or a Federal branch or agency. This information may be disclosed to other persons or governmental authorities.

Our authority for requesting this information is 12 U.S.C. § 1 et seq. and Executive Order 9397. Your provision of this information is voluntary. However, if you do not provide us with this information, it may adversely affect our ability to consider you.