Form 8821Tax Information Authorization
For IRS Use only:
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Function
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1 Taxpayer information. Taxpayer must sign and date this form on line 6.
Taxpayer name and address
Taxpayer identification number(s)
Daytime telephone number
Format: (000) 000-0000.
Plan number (if applicable)
2 Designee(s). If you wish to name more than two designees, attach a list to this form.
1
Check here if a list of additional designees is attached
Designee 1 Name and address
Designee 1 CAF No.
Designee 1 PTIN
Designee 1 Telephone No.
Format: (000) 000-0000.
Designee 1 Fax No.
Format: (000) 000-0000.
2
Check if to be sent copies of notices and communications
Designee 1 Check if new: Address, Telephone No., Fax No.
Address
Telephone No.
Fax No.
Designee 2 Name and address
Designee 2 CAF No.
Designee 2 PTIN
Designee 2 Telephone No.
Format: (000) 000-0000.
Designee 2 Fax No.
Format: (000) 000-0000.
3
Check if to be sent copies of notices and communications
Designee 2 Check if new: Address, Telephone No., Fax No.
Address
Telephone No.
Fax No.
3 Tax information. Each designee is authorized to inspect and/or receive confidential tax information for the type of tax, forms, periods, and specific matters you list below. See the line 3 instructions.
4
By checking here, I authorize access to my IRS records via an Intermediate Service Provider.
Rows
(a) Type of Tax Information (Income, Employment, Payroll, Excise, Estate, Gift, Civil Penalty, Sec. 4980H Payments, etc.)
(b) Tax Form Number (1040, 941, 720, etc.)
(c) Year(s) or Period(s)
(d) Specific Tax Matters
1
2
3
4 Specific use not recorded on the Centralized Authorization File (CAF)Â If you check this box, skip line 5
5 Retention/revocation of prior tax information authorizations. If the line 4 box is checked, skip this line. If the line 4 bax isn't checked, the IRS will automatically revoke all prior tax information authorizations on file unless you check the line 5 box and attach a copy of the tax information authorization(s) that you want to retain... To revoke a prior tax information authorizations) without submitting a new authorization, see the line 5 instructions.
6 Taxpayer signature. If signed by a corporate officer, partner, guardian, partnership representative (or designated individual, if applicable), executor, receiver, administrator, trustee, or individual other than the taxpayer, I certify that I have the legal authority to execute this form with respect to the tax matters and tax periods shown on line 3 above.
â–¶ IF NOT COMPLETED, SIGNED, AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.
â–¶ DON'T SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print Name
*
First Name
Last Name
Title (if applicable)
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