Consumer Agreement
for PCA Fiscal
Intermediary Services
Q
Q
Q
Q
Q
Q
Q
Acuerdo del consumidor
para servicios de
intermediario fiscal de PCA
I am a consumer of MassHealth-approved Personal
Care Attendant Services (“PCA Services”).
As a consumer of PCA Services, I employ my own
Personal Care Attendants (“PCAs”).
I understand that the wages paid to my PCA(s) are
established through a collective bargaining agreement
between the PCA Quality Homecare Workforce
Council (the Council) and the Union (SEIU Local
1199).
As the employer of my PCAs, I must perform
certain tasks (“Employer-Required Tasks”) such as
paying federal and state taxes and buying workers’
compensation insurance.
I understand that MassHealth has hired companies
called fiscal intermediaries (“FIs”) who can help
consumers like me perform the Employer-Required
Tasks.
I understand that the fiscal intermediary that my
personal care agency has chosen will be my FI.
I understand that I must let my FI know, by filling out
this form and returning it to my FI, whether I want the
FI to help me with my Employer-Required Tasks.
Q
Q
Q
Q
Q
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If I want the FI to help me with my Employer-Required
Tasks, I should choose Option One (Consumer-Delegated
Employer Option).
Q
If I do not want the FI to help me with my EmployerRequired Tasks, I should choose Option Two (ConsumerDirected Employer Option).
Q
Q
Si quisiera que el FI me ayude con las Tareas requeridas
del empleador, debo escoger la Opción uno (Opción de
empleador: Opción delegada por el consumidor).
I understand that I must read the explanations of
Option One and Option Two below, and then choose
an option by checking one of the boxes at the end of
this Agreement.
I understand that my personal care agency or my
fiscal intermediary can answer any questions I have
about Option One or Option Two, give me more
information, and help me choose which option is best
for me.
Si no quisiera que el FI me ayude con las Tareas
requeridas del empleador, debo escoger la Opción
dos (Opción de empleador: Opción dirigida por el
consumidor).
Q
Q
Entiendo que debo leer las explicaciones de la Opción
uno y la Opción dos al final de este acuerdo, y luego
escoger una opción marcando una de las casillas al
final de este Acuerdo.
Entiendo que mi agencia de atención individual o
mi intermediario fiscal puede responder cualquier
pregunta que yo tenga sobre la Opción uno u Opción
dos, darme más información y ayudarme a escoger la
opción que más me convenga.
Q
Q
Q
Q
Q
Q
Q
1
Acuerdo del consumidor
para servicios de
intermediario fiscal de PCA
I am a consumer of MassHealth-approved Personal
Care Attendant Services (“PCA Services”).
As a consumer of PCA Services, I employ my own
Personal Care Attendants (“PCAs”).
I understand that the wages paid to my PCA(s) are
established through a collective bargaining agreement
between the PCA Quality Homecare Workforce
Council (the Council) and the Union (SEIU Local
1199).
As the employer of my PCAs, I must perform
certain tasks (“Employer-Required Tasks”) such as
paying federal and state taxes and buying workers’
compensation insurance.
I understand that MassHealth has hired companies
called fiscal intermediaries (“FIs”) who can help
consumers like me perform the Employer-Required
Tasks.
I understand that the fiscal intermediary that my
personal care agency has chosen will be my FI.
I understand that I must let my FI know, by filling out
this form and returning it to my FI, whether I want the
FI to help me with my Employer-Required Tasks.
Q
Q
Q
Q
Q
Q
If I want the FI to help me with my Employer-Required
Tasks, I should choose Option One (Consumer-Delegated
Employer Option).
Q
If I do not want the FI to help me with my EmployerRequired Tasks, I should choose Option Two (ConsumerDirected Employer Option).
Q
Q
Si no quisiera que el FI me ayude con las Tareas
requeridas del empleador, debo escoger la Opción
dos (Opción de empleador: Opción dirigida por el
consumidor).
Q
Q
Entiendo que debo leer las explicaciones de la Opción
uno y la Opción dos al final de este acuerdo, y luego
escoger una opción marcando una de las casillas al
final de este Acuerdo.
Entiendo que mi agencia de atención individual o
mi intermediario fiscal puede responder cualquier
pregunta que yo tenga sobre la Opción uno u Opción
dos, darme más información y ayudarme a escoger la
opción que más me convenga.
(continúa en la sección de la derecha de la página 2)
(continued on left half of page 2)
PCA-3 (REV 06/09)
Soy consumidor del programa autorizado de
MassHealth, Personal Care Attendant Services
[Servicios de ayudantes de atención individual
(“Servicios PCA”)].
Como consumidor de los Servicios PCA, contrato a
mis propios Ayudantes de atención individual
(“PCAs“).
Entiendo que los salarios pagados a mi(s) PCA(s)
se han establecido por medio de un acuerdo de
negociación colectiva entre el PCA Quality Homecare
Workforce Council (el Concejo) y el Sindicato (SEIU
Local 1199).
Como empleador de mis PCAs, debo realizar ciertas
funciones (“Tareas requeridas del empleador”) tales
como pagar los impuestos federales y estatales, y
adquirir seguro de accidentes de trabajo.
Tengo entendido que MassHealth ha contratado a
unas compañías conocidas como intermediarios
fiscales (“FIs“), los cuales pueden ayudar a usuarios
como yo, a realizar las Tareas requeridas del
empleador.
Entiendo que el intermediario fiscal que mi agencia
de atención individual seleccionó será mi FI.
Entiendo que al completar y entregar este formulario
a mi FI, le debo informar si deseo sus servicios
para asistirme a realizar mis Tareas requeridas del
empleador.
Si quisiera que el FI me ayude con las Tareas requeridas
del empleador, debo escoger la Opción uno (Opción de
empleador: Opción delegada por el consumidor).
I understand that I must read the explanations of
Option One and Option Two below, and then choose
an option by checking one of the boxes at the end of
this Agreement.
I understand that my personal care agency or my
fiscal intermediary can answer any questions I have
about Option One or Option Two, give me more
information, and help me choose which option is best
for me.
(continúa en la sección de la derecha de la página 2)
(continued on left half of page 2)
PCA-3 (REV 06/09)
Soy consumidor del programa autorizado de
MassHealth, Personal Care Attendant Services
[Servicios de ayudantes de atención individual
(“Servicios PCA”)].
Como consumidor de los Servicios PCA, contrato a
mis propios Ayudantes de atención individual
(“PCAs“).
Entiendo que los salarios pagados a mi(s) PCA(s)
se han establecido por medio de un acuerdo de
negociación colectiva entre el PCA Quality Homecare
Workforce Council (el Concejo) y el Sindicato (SEIU
Local 1199).
Como empleador de mis PCAs, debo realizar ciertas
funciones (“Tareas requeridas del empleador”) tales
como pagar los impuestos federales y estatales, y
adquirir seguro de accidentes de trabajo.
Tengo entendido que MassHealth ha contratado a
unas compañías conocidas como intermediarios
fiscales (“FIs“), los cuales pueden ayudar a usuarios
como yo, a realizar las Tareas requeridas del
empleador.
Entiendo que el intermediario fiscal que mi agencia
de atención individual seleccionó será mi FI.
Entiendo que al completar y entregar este formulario
a mi FI, le debo informar si deseo sus servicios
para asistirme a realizar mis Tareas requeridas del
empleador.
Consumer Agreement
for PCA Fiscal
Intermediary Services
1
(continued from left half of page 1)
Q
(proviene de la sección de la derecha de la página 1)
I understand that if I have a surrogate, I must choose
Option One, unless I have a legal guardian and my
legal guardian chooses Option Two.
Q
Q
Q
Q
Q
Q
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Opción uno, a no ser que tenga un tutor legal y mi
tutor legal elija la Opción dos.
I understand that no matter which option I choose,
I must:
Q
Entiendo que si tengo un sustituto, debo escoger la
(continued from left half of page 1)
notify my FI any time I hire or fire a PCA, any time
that I move, and any time one of my PCAs moves;
notify my FI and my personal care agency when I
am admitted to a nursing facility or other inpatient
facility. I understand that MassHealth and the FI
cannot pay for activity time performed by my PCA
when I am in a nursing facility or other inpatient
facility, and that any payments made while I am in
a nursing facility or inpatient facility are considered
fraud and will be reported to the state Bureau of
Special Investigations for investigation, and may
result in termination of my PCA services as well as
other potential penalties;
make sure that each week my PCAs sign their time
sheets (“Activity Forms”), and fill them out correctly;
make sure my PCA activity forms accurately reflect
the days and hours my PCA worked for me;
send my PCAs’ completed Activity Forms to my
FI, following my FI’s instructions, that accurately
represent the hours my PCA(s) worked for me; and
follow the MassHealth regulations for the Personal
Care Attendant Program. My personal care agency
can provide me with a copy of these regulations; and
I understand that MassHealth and the FI cannot pay my
PCA if my PCA is on the List of Excluded Individuals/
Entities (LEIE) maintained by the U.S. Department of
Health and Human Services Office of Inspector General
(OIG). My FI or my personal care agency can provide me
with more information about this.
I must have prior authorization for PCA services from
MassHealth before my PCAs start working for me.
I understand that I may lose my eligibility for PCA
services if I do not complete and return this form to my
FI as instructed.
I understand that no matter which option I choose,
I must:
notificar a mi FI siempre que contrate o despida a un
PCA, siempre que cambie de dirección y siempre que
cualquiera de mis PCAs cambie de dirección;
Q notificar a mi FI y a mi agencia de atención individual
cuando sea internado en una institución de atención
especializada u otra institución para pacientes
internos. Entiendo que MassHealth y el FI no pueden
pagar por el tiempo de las actividades realizadas por
mi PCA cuando yo esté en una institución de atención
especializada u otra institución para pacientes
internos, y que cualquier pago que se haga mientras
esté en una institución de atención especializada
u otra institución para pacientes internos se
considera fraude y será reportado al Departamento
de investigaciones especiales para su respectiva
investigación, pudiendo dar como resultado la
terminación de los servicios de mi PCA al igual que
otras multas posibles;
Q comprobar que mis PCAs firmen semanalmente su
hoja de asistencia (“Formularios de actividades”), y
que las llenen correctamente;
Q comprobar que los formularios de actividades de mi
PCA reflejan con precisión los dias y horas en que mi
PCA trabajó para mí;
Q enviar los Formularios de actividades de mis PCAs
completados a mi FI, de acuerdo a las instrucciones
de mi FI, que representan las horas exactas que mi(s)
PCA(s) trabajó (trabajaron) para mí; y
Q cumplir con las normas de MassHealth sobre el
Programa de ayudantes de atención individual. Mi
agencia de atención individual me puede dar una
copia de dichas normas; y
Entiendo que MassHealth y el FI no pueden pagarle al
PCA si dicha persona está en la Lista de individuos/
entidades excluidas (LEIE, por sus siglas en inglés) que
mantiene la Oficina del Inspector general (OIG, por sus
siglas en inglés) del Departamento de salud y servicios
humanos de los E.E.U.U. Mi FI o mi agencia de atención
individual puede proporcionarme más información sobre
esto.
Debo tener autorización previa de MassHealth para
los servicios PCA antes de que mis PCAs comiencen a
trabajar para mí.
Entiendo que puedo perder mi eligibilidad para los
servicios PCA si no completo y devuelvo este formulario
a mi FI tal como aquí se indica.
Q
(continúa en la sección de la derecha de la página 3)
(continued on left half of page 3)
2
I understand that if I have a surrogate, I must choose
Option One, unless I have a legal guardian and my
legal guardian chooses Option Two.
Entiendo que no importa cuál opción escoja, tengo la
obligación de:
Q
Q
Q
Q
Q
Q
(proviene de la sección de la derecha de la página 1)
Q
Entiendo que si tengo un sustituto, debo escoger la
Opción uno, a no ser que tenga un tutor legal y mi
tutor legal elija la Opción dos.
Entiendo que no importa cuál opción escoja, tengo la
obligación de:
notify my FI any time I hire or fire a PCA, any time
that I move, and any time one of my PCAs moves;
notify my FI and my personal care agency when I
am admitted to a nursing facility or other inpatient
facility. I understand that MassHealth and the FI
cannot pay for activity time performed by my PCA
when I am in a nursing facility or other inpatient
facility, and that any payments made while I am in
a nursing facility or inpatient facility are considered
fraud and will be reported to the state Bureau of
Special Investigations for investigation, and may
result in termination of my PCA services as well as
other potential penalties;
make sure that each week my PCAs sign their time
sheets (“Activity Forms”), and fill them out correctly;
make sure my PCA activity forms accurately reflect
the days and hours my PCA worked for me;
send my PCAs’ completed Activity Forms to my
FI, following my FI’s instructions, that accurately
represent the hours my PCA(s) worked for me; and
notificar a mi FI siempre que contrate o despida a un
PCA, siempre que cambie de dirección y siempre que
cualquiera de mis PCAs cambie de dirección;
Q notificar a mi FI y a mi agencia de atención individual
cuando sea internado en una institución de atención
especializada u otra institución para pacientes
internos. Entiendo que MassHealth y el FI no pueden
pagar por el tiempo de las actividades realizadas por
mi PCA cuando yo esté en una institución de atención
especializada u otra institución para pacientes
internos, y que cualquier pago que se haga mientras
esté en una institución de atención especializada
u otra institución para pacientes internos se
considera fraude y será reportado al Departamento
de investigaciones especiales para su respectiva
investigación, pudiendo dar como resultado la
terminación de los servicios de mi PCA al igual que
otras multas posibles;
Q comprobar que mis PCAs firmen semanalmente su
hoja de asistencia (“Formularios de actividades”), y
que las llenen correctamente;
Q comprobar que los formularios de actividades de mi
PCA reflejan con precisión los dias y horas en que mi
PCA trabajó para mí;
Q enviar los Formularios de actividades de mis PCAs
completados a mi FI, de acuerdo a las instrucciones
de mi FI, que representan las horas exactas que mi(s)
PCA(s) trabajó (trabajaron) para mí; y
Q cumplir con las normas de MassHealth sobre el
Programa de ayudantes de atención individual. Mi
agencia de atención individual me puede dar una
copia de dichas normas; y
Entiendo que MassHealth y el FI no pueden pagarle al
PCA si dicha persona está en la Lista de individuos/
entidades excluidas (LEIE, por sus siglas en inglés) que
mantiene la Oficina del Inspector general (OIG, por sus
siglas en inglés) del Departamento de salud y servicios
humanos de los E.E.U.U. Mi FI o mi agencia de atención
individual puede proporcionarme más información sobre
esto.
Debo tener autorización previa de MassHealth para
los servicios PCA antes de que mis PCAs comiencen a
trabajar para mí.
Entiendo que puedo perder mi eligibilidad para los
servicios PCA si no completo y devuelvo este formulario
a mi FI tal como aquí se indica.
Q
follow the MassHealth regulations for the Personal
Care Attendant Program. My personal care agency
can provide me with a copy of these regulations; and
I understand that MassHealth and the FI cannot pay my
PCA if my PCA is on the List of Excluded Individuals/
Entities (LEIE) maintained by the U.S. Department of
Health and Human Services Office of Inspector General
(OIG). My FI or my personal care agency can provide me
with more information about this.
I must have prior authorization for PCA services from
MassHealth before my PCAs start working for me.
I understand that I may lose my eligibility for PCA
services if I do not complete and return this form to my
FI as instructed.
(continúa en la sección de la derecha de la página 3)
(continued on left half of page 3)
2
(continued from left half of page 2)
EXPLANATION OF
Option One
( CONSUMER - DELEGATED
Q
Q
(proviene de la sección de la derecha de la página 2)
EXPLICACIÓN DE LA
EMPLOYER OPTION )
( OPCIÓN
Under Option One, I choose to have my FI perform my
Employer-Required Tasks.
Under Option One, my FI will:
s WRITEOUTMYPAYROLLCHECKSFORMEINTHENAMEOF
each PCA that worked for me;
s MAKECORRECTWITHHOLDINGSFROMMY0#!S
paychecks;
s MAKEDEDUCTIONSFOR0#!UNIONDUESANDFEES
in accordance with the collective bargaining
agreement between the PCA Quality Homecare
Workforce Council and the Union (SEIU Local 1199);
s SENDALLMONEYWITHHELDFROMMY0#!SPAYCHECKS
to the proper agencies;
s PAYMYFEDERALSTATEANDLOCALEMPLOYMENTTAXES
for me;
s PAYMYUNEMPLOYMENTINSURANCETAXESFORME
s PURCHASEWORKERSCOMPENSATIONINSURANCEINMY
name to cover my PCAs;
s send me the completed paychecks every two weeks
for me to distribute to my PCAs — OR —
Q
Q
s DEPOSITMY0#!SPAYCHECKSDIRECTLYINTOMY
PCAs’ bank accounts if I tell the FI to do this. (I
understand that MassHealth regulations require me
to inform my PCAs of the option to have my PCA
payments direct-deposited into the PCA’s
bank account.);
s PERFORMOTHER%MPLOYER2EQUIRED4ASKSSUCHAS
getting Employer Identification Numbers (EINs)
and filling out, filing, and saving copies of other
required employment forms;
s SENDMESUMMARIESOFMYPAYROLLSANDMYTAX
filings; and
s SENDMESUMMARIESOFMYREMAININGHOURSOF0#!
services when I request this from my FI.
If I choose Option One, I understand that I must sign
certain forms that will allow the FI to act on my behalf.
I understand my PCAs cannot be paid until these forms
are completed and returned to my FI. My FI will send me
these forms.
My FI will also do other Employer-Required Tasks such
as getting EINs and filling out, filing, and saving copies
of other required employment forms.
Opción uno
DEL EMPLEADOR : DELEGADA POR EL CONSUMIDOR )
Bajo la Opción uno, opto por solicitar los
servicios de un FI para que realice mis Tareas
requeridas del empleador.
Bajo la Opción uno, mi FI:
s ESCRIBIRÉPORMÓLOSCHEQUESDENØMINAANOMBREDE
cada uno de los PCA que hayan trabajado para mí;
s EFECTUARÉLASRETENCIONESCORRESPONDIENTESDELOS
cheques de sueldo de mis PCAs;
s hará deducciones para las cuotas y aranceles del
sindicato de PCA de acuerdo con la negociación
colectiva entre el PCA Quality Homecare Workforce
Council y el Sindicato (SEIU Local 1199);
s ENVIARÉTODODINERORETENIDODELOSCHEQUES
de sueldo de mis PCAs a las agencias
correspondientes;
s PAGARÉPORMÓMISIMPUESTOSDEEMPLEOFEDERALES
estatales y locales;
s PAGARÉMISIMPUESTOSDESEGURODEDESEMPLEO
por mí;
s ADQUIRIRÉELSEGURODEACCIDENTESDETRABAJOENMI
nombre para cubrir a mis PCAs;
s MEENVIARÉCADADOSSEMANASLOSCHEQUESDE
sueldo llenados para que yo los entregue a mis
PCAs — O —
s DEPOSITARÉLOSCHEQUESDESUELDODIRECTAMENTE
en las cuentas bancarias de mis PCAs, si así se
lo pido. (Entiendo que las normas de MassHealth
requieren que yo informe a mis PCAs de su opción
de recibir mis cheques directamente en su cuenta
bancaria.);
s REALIZARÉOTRAS4AREASPROPIASDEUNEMPLEADOR
tales como obtener un Número de identificación
del empleador (EINs, por sus siglas en inglés) y
completar, presentar y guardar las copias de los
demás formularios de empleo obligatorios;
s MEENVIARÉRESÞMENESDEMINØMINAY
presentaciones de impuestos; y
s MEENVIARÉRESÞMENESDELASHORASRESTANTESDEMIS
servicios de PCA cuando yo lo solicite de mi FI.
Si opto por la Opción uno, entiendo que debo firmar
ciertos formularios que le permitirán al FI actuar en
mi nombre. Entiendo que mis PCAs no pueden recibir
su paga hasta que estos formularios sean llenados y
devueltos a mi FI. Mi FI me enviará dichos formularios.
Mi Fi también hará otras Tareas requeridas del
empleador tales como obtener los EINs y completar,
presentar y guardar copias de otros formularios de
empleo obligatorios.
(continued on left half of page 4)
(continúa en la sección de la derecha de la página 4)
3
(continued from left half of page 2)
EXPLANATION OF
Option One
( CONSUMER - DELEGATED
Q
Q
(proviene de la sección de la derecha de la página 2)
EXPLICACIÓN DE LA
EMPLOYER OPTION )
( OPCIÓN
Under Option One, I choose to have my FI perform my
Employer-Required Tasks.
Under Option One, my FI will:
s WRITEOUTMYPAYROLLCHECKSFORMEINTHENAMEOF
each PCA that worked for me;
s MAKECORRECTWITHHOLDINGSFROMMY0#!S
paychecks;
s MAKEDEDUCTIONSFOR0#!UNIONDUESANDFEES
in accordance with the collective bargaining
agreement between the PCA Quality Homecare
Workforce Council and the Union (SEIU Local 1199);
s SENDALLMONEYWITHHELDFROMMY0#!SPAYCHECKS
to the proper agencies;
s PAYMYFEDERALSTATEANDLOCALEMPLOYMENTTAXES
for me;
s PAYMYUNEMPLOYMENTINSURANCETAXESFORME
s PURCHASEWORKERSCOMPENSATIONINSURANCEINMY
name to cover my PCAs;
s send me the completed paychecks every two weeks
for me to distribute to my PCAs — OR —
Q
Q
s DEPOSITMY0#!SPAYCHECKSDIRECTLYINTOMY
PCAs’ bank accounts if I tell the FI to do this. (I
understand that MassHealth regulations require me
to inform my PCAs of the option to have my PCA
payments direct-deposited into the PCA’s
bank account.);
s PERFORMOTHER%MPLOYER2EQUIRED4ASKSSUCHAS
getting Employer Identification Numbers (EINs)
and filling out, filing, and saving copies of other
required employment forms;
s SENDMESUMMARIESOFMYPAYROLLSANDMYTAX
filings; and
s SENDMESUMMARIESOFMYREMAININGHOURSOF0#!
services when I request this from my FI.
If I choose Option One, I understand that I must sign
certain forms that will allow the FI to act on my behalf.
I understand my PCAs cannot be paid until these forms
are completed and returned to my FI. My FI will send me
these forms.
My FI will also do other Employer-Required Tasks such
as getting EINs and filling out, filing, and saving copies
of other required employment forms.
Opción uno
DEL EMPLEADOR : DELEGADA POR EL CONSUMIDOR )
Bajo la Opción uno, opto por solicitar los
servicios de un FI para que realice mis Tareas
requeridas del empleador.
Bajo la Opción uno, mi FI:
s ESCRIBIRÉPORMÓLOSCHEQUESDENØMINAANOMBREDE
cada uno de los PCA que hayan trabajado para mí;
s EFECTUARÉLASRETENCIONESCORRESPONDIENTESDELOS
cheques de sueldo de mis PCAs;
s hará deducciones para las cuotas y aranceles del
sindicato de PCA de acuerdo con la negociación
colectiva entre el PCA Quality Homecare Workforce
Council y el Sindicato (SEIU Local 1199);
s ENVIARÉTODODINERORETENIDODELOSCHEQUES
de sueldo de mis PCAs a las agencias
correspondientes;
s PAGARÉPORMÓMISIMPUESTOSDEEMPLEOFEDERALES
estatales y locales;
s PAGARÉMISIMPUESTOSDESEGURODEDESEMPLEO
por mí;
s ADQUIRIRÉELSEGURODEACCIDENTESDETRABAJOENMI
nombre para cubrir a mis PCAs;
s MEENVIARÉCADADOSSEMANASLOSCHEQUESDE
sueldo llenados para que yo los entregue a mis
PCAs — O —
s DEPOSITARÉLOSCHEQUESDESUELDODIRECTAMENTE
en las cuentas bancarias de mis PCAs, si así se
lo pido. (Entiendo que las normas de MassHealth
requieren que yo informe a mis PCAs de su opción
de recibir mis cheques directamente en su cuenta
bancaria.);
s REALIZARÉOTRAS4AREASPROPIASDEUNEMPLEADOR
tales como obtener un Número de identificación
del empleador (EINs, por sus siglas en inglés) y
completar, presentar y guardar las copias de los
demás formularios de empleo obligatorios;
s MEENVIARÉRESÞMENESDEMINØMINAY
presentaciones de impuestos; y
s MEENVIARÉRESÞMENESDELASHORASRESTANTESDEMIS
servicios de PCA cuando yo lo solicite de mi FI.
Si opto por la Opción uno, entiendo que debo firmar
ciertos formularios que le permitirán al FI actuar en
mi nombre. Entiendo que mis PCAs no pueden recibir
su paga hasta que estos formularios sean llenados y
devueltos a mi FI. Mi FI me enviará dichos formularios.
Mi Fi también hará otras Tareas requeridas del
empleador tales como obtener los EINs y completar,
presentar y guardar copias de otros formularios de
empleo obligatorios.
(continued on left half of page 4)
(continúa en la sección de la derecha de la página 4)
3
(continued from left half of page 3)
EXPLANATION OF
(proviene de la sección de la derecha de la página 3)
Option Two
( CONSUMER - DIRECTED
EXPLICACIÓN DE LA
EMPLOYER OPTION )
( OPCIÓN
Opción dos
DEL EMPLEADOR : DIRIGIDA POR EL CONSUMIDOR )
Under Option Two, I choose to perform the EmployerRequired Tasks myself.
Bajo la Opción dos, opto por realizar por mí mismo las
tareas requeridas del empleador.
Under Option Two, I will
s SUBMITMY0#!SACTIVITYFORMSTOTHE&)
as instructed;
s ENSURETHATMY0#!ACTIVITYFORMSACCURATELY
reflect the day and hours my PCA worked;
s PROCESSMYPAYROLLFORALLOFMY0#!S
s PAYMY0#!SCORRECTLYANDONTIME
s SENDALLMONEYWITHHELDFROMMY0#!SPAYCHECKS
to the proper agencies;
s PURCHASEWORKERSCOMPENSATIONINSURANCEFOR
my PCAs;
s PAYMY0#!STHEHOURLYWAGEESTABLISHEDTHROUGH
the collective bargaining agreement between the
PCA Quality Homecare Workforce Council and the
Union (SEIU Local 1199). (The FI can tell me what
these rates are.);
s file and pay my own federal, state, and local
employment taxes;
s file and pay my own unemployment
insurance taxes;
s not hire a PCA whose name appears on the List of
Excluded Individuals/Entities (LEIE) maintained by
the U.S. Office of Inspector General (OIG).
MassHealth and the FI cannot pay a PCA who is
on the LEIE. My FI or my personal care agency can
provide me with information about this;
s make correct withholdings from my PCAs’
paychecks;
s make deductions for PCA union dues and fees
in accordance with the collective bargaining
agreement between the PCA Quality Homecare
Workforce Council and the Union (SEIU Local
1199) and forward the dues and fees collected to
the Union.
I understand I can contact my FI to obtain the phone
number for SEIU if I have any questions about this; and
s GIVEPROOFTOTHE&)WHENREQUESTEDTHAT)HAVE
done all these tasks correctly.
Under Option Two, the FI will send me one check every
two weeks. I will use this money solely to pay for my
Employer-Required Tasks as described above.
Q
Q
(continued on left half of page 5)
Bajo la Opción dos:
s ENVIARÏLOSFORMULARIOSDEACTIVIDADESDEMIS0#!S
al FI tal como se indica;
s MEASEGURARÏQUELOSFORMULARIOSDEACTIVIDADES
de mis PCAs reflejan con precisión los días y las
horas en que mi PCA trabajó;
s PROCESARÏMINØMINAPARATODOSMIS0#!S
s PAGARÏAMIS0#!SCORRECTAMENTEYATIEMPO
s ENVIARÏELDINERORETENIDODELOSCHEQUESDESUELDO
de mis PCAs a las agencias correspondientes;
s OBTENDRÏELSEGURODEACCIDENTESDETRABAJOPARA
mis PCAs;
s PAGARÏAMIS0#!ELSALARIOPORHORAESTABLECIDO
a través de la negociación colectiva entre el PCA
Quality Homecare Workforce Council y el Sindicato
(SEIU Local 1199). (El FI puede informarme cuáles
son estos salarios.);
s PRESENTARÏYPAGARÏPORCUENTAPROPIAMIS
impuestos de empleo federales, estatales y locales;
s PRESENTARÏYPAGARÏPORCUENTAPROPIAMIS
impuestos de seguro de desempleo;
s NOCONTRATARÏAUN0#!CUYONOMBREAPARECEEN
la Lista de individuos/entidades excluidas (LEIE,
por sus siglas en inglés) que mantiene la Oficina
del inspector general de los E.E.U.U. (OIG, por sus
siglas en inglés).
Ni MassHealth ni el FI pueden pagarle a un
PCA que no esté en la LEIE. Mi FI o mi agencia
de atención personal puede proporcionarme
información sobre esto;
s HARé las retenciones apropiadas de los cheques de
mi(s) PCAs;
s HARé deducciones para las cuotas y aranceles del
sindicato de PCA de acuerdo con la negociación
colectiva entre el PCA Quality Homecare Workforce
Council y el Sindicato (SEIU Local 1199) y enviaré
las cuotas y aranceles recaudados al Sindicato.
Entiendo que puedo comunicarme con mi FI para
obtener el número telefónico del SEIU si deseo hacer
preguntas al respecto; y
4
s PRESENTARÏLAPRUEBAAMI&)CUANDOASÓLOPIDA
de que he realizado todas esas tareas
correctamente.
Bajo la Opción dos, el FI me enviará un cheque cada
dos semanas. Usaré ese dinero, sólo para pagar por mis
Tareas requeridas del empleador tal como se describen
anteriormente. (continúa en la sección de la derecha de la página 5)
(continued from left half of page 3)
EXPLANATION OF
(proviene de la sección de la derecha de la página 3)
Option Two
( CONSUMER - DIRECTED
EXPLICACIÓN DE LA
EMPLOYER OPTION )
( OPCIÓN
Opción dos
DEL EMPLEADOR : DIRIGIDA POR EL CONSUMIDOR )
Under Option Two, I choose to perform the EmployerRequired Tasks myself.
Bajo la Opción dos, opto por realizar por mí mismo las
tareas requeridas del empleador.
Under Option Two, I will
s SUBMITMY0#!SACTIVITYFORMSTOTHE&)
as instructed;
s ENSURETHATMY0#!ACTIVITYFORMSACCURATELY
reflect the day and hours my PCA worked;
s PROCESSMYPAYROLLFORALLOFMY0#!S
s PAYMY0#!SCORRECTLYANDONTIME
s SENDALLMONEYWITHHELDFROMMY0#!SPAYCHECKS
to the proper agencies;
s PURCHASEWORKERSCOMPENSATIONINSURANCEFOR
my PCAs;
s PAYMY0#!STHEHOURLYWAGEESTABLISHEDTHROUGH
the collective bargaining agreement between the
PCA Quality Homecare Workforce Council and the
Union (SEIU Local 1199). (The FI can tell me what
these rates are.);
s file and pay my own federal, state, and local
employment taxes;
s file and pay my own unemployment
insurance taxes;
s not hire a PCA whose name appears on the List of
Excluded Individuals/Entities (LEIE) maintained by
the U.S. Office of Inspector General (OIG).
MassHealth and the FI cannot pay a PCA who is
on the LEIE. My FI or my personal care agency can
provide me with information about this;
s make correct withholdings from my PCAs’
paychecks;
s make deductions for PCA union dues and fees
in accordance with the collective bargaining
agreement between the PCA Quality Homecare
Workforce Council and the Union (SEIU Local
1199) and forward the dues and fees collected to
the Union.
I understand I can contact my FI to obtain the phone
number for SEIU if I have any questions about this; and
s GIVEPROOFTOTHE&)WHENREQUESTEDTHAT)HAVE
done all these tasks correctly.
Under Option Two, the FI will send me one check every
two weeks. I will use this money solely to pay for my
Employer-Required Tasks as described above.
Q
Q
(continued on left half of page 5)
Bajo la Opción dos:
s ENVIARÏLOSFORMULARIOSDEACTIVIDADESDEMIS0#!S
al FI tal como se indica;
s MEASEGURARÏQUELOSFORMULARIOSDEACTIVIDADES
de mis PCAs reflejan con precisión los días y las
horas en que mi PCA trabajó;
s PROCESARÏMINØMINAPARATODOSMIS0#!S
s PAGARÏAMIS0#!SCORRECTAMENTEYATIEMPO
s ENVIARÏELDINERORETENIDODELOSCHEQUESDESUELDO
de mis PCAs a las agencias correspondientes;
s OBTENDRÏELSEGURODEACCIDENTESDETRABAJOPARA
mis PCAs;
s PAGARÏAMIS0#!ELSALARIOPORHORAESTABLECIDO
a través de la negociación colectiva entre el PCA
Quality Homecare Workforce Council y el Sindicato
(SEIU Local 1199). (El FI puede informarme cuáles
son estos salarios.);
s PRESENTARÏYPAGARÏPORCUENTAPROPIAMIS
impuestos de empleo federales, estatales y locales;
s PRESENTARÏYPAGARÏPORCUENTAPROPIAMIS
impuestos de seguro de desempleo;
s NOCONTRATARÏAUN0#!CUYONOMBREAPARECEEN
la Lista de individuos/entidades excluidas (LEIE,
por sus siglas en inglés) que mantiene la Oficina
del inspector general de los E.E.U.U. (OIG, por sus
siglas en inglés).
Ni MassHealth ni el FI pueden pagarle a un
PCA que no esté en la LEIE. Mi FI o mi agencia
de atención personal puede proporcionarme
información sobre esto;
s HARé las retenciones apropiadas de los cheques de
mi(s) PCAs;
s HARé deducciones para las cuotas y aranceles del
sindicato de PCA de acuerdo con la negociación
colectiva entre el PCA Quality Homecare Workforce
Council y el Sindicato (SEIU Local 1199) y enviaré
las cuotas y aranceles recaudados al Sindicato.
Entiendo que puedo comunicarme con mi FI para
obtener el número telefónico del SEIU si deseo hacer
preguntas al respecto; y
4
s PRESENTARÏLAPRUEBAAMI&)CUANDOASÓLOPIDA
de que he realizado todas esas tareas
correctamente.
Bajo la Opción dos, el FI me enviará un cheque cada
dos semanas. Usaré ese dinero, sólo para pagar por mis
Tareas requeridas del empleador tal como se describen
anteriormente. (continúa en la sección de la derecha de la página 5)
(proviene de la sección de la derecha de la página 4)
(continued from left half of page 4)
Here Is My Choice:
(proviene de la sección de la derecha de la página 4)
(continued from left half of page 4)
Here Is My Choice:
I choose Option One (Consumer-Delegated
option) because I want to have the FI perform my
Employer-Required Tasks for me.
I choose Option Two (Consumer-Directed option)
because I want to perform my Employer-Required
Tasks myself. I understand that I can change my
option, but that I have to tell the FI at least 10 days
before I want to make the change.
I choose Option One (Consumer-Delegated
option) because I want to have the FI perform my
Employer-Required Tasks for me.
I choose Option Two (Consumer-Directed option)
because I want to perform my Employer-Required
Tasks myself. I understand that I can change my
option, but that I have to tell the FI at least 10 days
before I want to make the change.
Esta es mi elección:
Elijo la Opción uno (Opción delegada por el
consumidor) porque deseo obtener los servicios de
un FI para que realice por mí las Tareas requeridas
del empleador.
Elijo la Opción dos (Opción dirigida por el
consumidor) porque deseo realizar por mí mismo
las Tareas requeridas del empleador. Entiendo que
puedo cambiar mi opción, pero debo informar al FI
por lo menos 10 días antes de realizar el cambio.
Esta es mi elección:
Elijo la Opción uno (Opción delegada por el
consumidor) porque deseo obtener los servicios de
un FI para que realice por mí las Tareas requeridas
del empleador.
Elijo la Opción dos (Opción dirigida por el
consumidor) porque deseo realizar por mí mismo
las Tareas requeridas del empleador. Entiendo que
puedo cambiar mi opción, pero debo informar al FI
por lo menos 10 días antes de realizar el cambio.
Here is my printed name
Mi nombre en letra de molde
Here is my printed name
Mi nombre en letra de molde
________________________________________________
_________________________________________________
________________________________________________
_________________________________________________
Here is my signature
Mi firma
Here is my signature
Mi firma
________________________________________________
_________________________________________________
________________________________________________
_________________________________________________
OR
O
OR
O
Here is my legal guardian’s signature
La firma de mi Tutor legal
Here is my legal guardian’s signature
La firma de mi Tutor legal
________________________________________________
_________________________________________________
________________________________________________
_________________________________________________
Today’s date
Fecha de hoy
Today’s date
Fecha de hoy
________________________________________________
_________________________________________________
________________________________________________
_________________________________________________
Commonwealth of Massachusetts
MassHealth
Commonwealth of Massachusetts
MassHealth
Commonwealth of Massachusetts
MassHealth
Commonwealth of Massachusetts
MassHealth
5
5
Form
8821
(Rev. October 2011)
Department of the Treasury
Internal Revenue Service
OMB No. 1545-1165
Tax Information Authorization
For IRS Use Only
Form
Received by:
Name
a Do
not sign this form unless all applicable lines have been completed.
a Do not use this form to request a copy or transcript of your tax return.
Instead, use Form 4506 or Form 4506-T.
Telephone
Department of the Treasury
Internal Revenue Service
Function
Date
1 Taxpayer information. Taxpayer(s) must sign and date this form on line 7.
Taxpayer name(s) and address (type or print)
Taxpayer identification number
INCOME TAX WITHHOLDING
SS-4, 940, 940R, 940EZ, 941,
INCOME TAX WITHHOLDING
941R, 941X, 941C
AND EMPLOYMENT TAXES
Received by:
Name
a Do
not sign this form unless all applicable lines have been completed.
a Do not use this form to request a copy or transcript of your tax return.
Instead, use Form 4506 or Form 4506-T.
Taxpayer name(s) and address (type or print)
Telephone
Function
Date
(c)
Year(s) or Period(s)
(see the instructions for line 3)
Taxpayer identification number
Daytime telephone number
Plan number (if applicable)
2 Appointee. If you wish to name more than one appointee, attach a list to this form.
CAF No.
Name and address
0302-31933R
PTIN
SEREN DERIN OR DESIGNATED REPRESENTATIVE FOR
Telephone No.
413-256-6692
STAVROS CENTER FOR INDEPENDENT LIVING
Fax No.
413-256-2630
P.O. BOX 2130, AMHERST, MA 01004
Check if new: Address
Telephone No.
Fax No.
3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the
tax matters listed on this line. Do not use Form 8821 to request copies of tax returns.
(b)
Tax Form Number
(1040, 941, 720, etc.)
For IRS Use Only
1 Taxpayer information. Taxpayer(s) must sign and date this form on line 7.
Daytime telephone number
(a)
Type of Tax
(Income, Employment, Excise, etc.)
or Civil Penalty
8821
(Rev. October 2011)
OMB No. 1545-1165
Tax Information Authorization
Plan number (if applicable)
2 Appointee. If you wish to name more than one appointee, attach a list to this form.
CAF No.
Name and address
0302-31933R
PTIN
SEREN DERIN OR DESIGNATED REPRESENTATIVE FOR
Telephone No.
413-256-6692
STAVROS CENTER FOR INDEPENDENT LIVING
Fax No.
413-256-2630
P.O. BOX 2130, AMHERST, MA 01004
Check if new: Address
Telephone No.
Fax No.
3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the
tax matters listed on this line. Do not use Form 8821 to request copies of tax returns.
(d)
Specific Tax Matters (see instr.)
TAX LIABILITY
843, W-2, W-2C, W-3, W-3C
(a)
Type of Tax
(Income, Employment, Excise, etc.)
or Civil Penalty
(b)
Tax Form Number
(1040, 941, 720, etc.)
INCOME TAX WITHHOLDING
SS-4, 940, 940R, 940EZ, 941,
INCOME TAX WITHHOLDING
941R, 941X, 941C
AND EMPLOYMENT TAXES
(c)
Year(s) or Period(s)
(see the instructions for line 3)
(d)
Specific Tax Matters (see instr.)
TAX LIABILITY
843, W-2, W-2C, W-3, W-3C
4 Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific
use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6
. . a
4 Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific
use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6
. . a
5 Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):
a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing
basis, check this box
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
Note. Appointees will no longer receive forms, publications and other related materials with the notices.
b If you do not want any copies of notices or communications sent to your appointee, check this box . . . . . . . a
5 Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):
a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing
basis, check this box
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
Note. Appointees will no longer receive forms, publications and other related materials with the notices.
b If you do not want any copies of notices or communications sent to your appointee, check this box . . . . . . . a
✔
6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior
authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want
to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect
and check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
To revoke this tax information authorization, see the instructions on page 4.
6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior
authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want
to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect
and check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
To revoke this tax information authorization, see the instructions on page 4.
7 Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign. If signed by a
corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify
that I have the authority to execute this form with respect to the tax matters/periods on line 3 above.
7 Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign. If signed by a
corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify
that I have the authority to execute this form with respect to the tax matters/periods on line 3 above.
a IF
a IF
NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.
a DO
Signature
Print Name
Date
Title (if applicable)
Signature
Print Name
PIN number for electronic signature
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.
a DO
NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.
Date
Title (if applicable)
PIN number for electronic signature
Cat. No. 11596P
Form 8821 (Rev. 10-2011)
✔
NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.
Signature
Print Name
Date
Title (if applicable)
Signature
Print Name
PIN number for electronic signature
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Date
Title (if applicable)
PIN number for electronic signature
Cat. No. 11596P
Form 8821 (Rev. 10-2011)
Page 2
Form 8821 (Rev. 10-2011)
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
What's New
Appointees will no longer receive inserts, such as forms,
publications, and other related materials, with notices.
Purpose of Form
Form 8821 authorizes any individual, corporation, firm,
organization, or partnership you designate to inspect and/or
receive your confidential information in any office of the IRS
for the type of tax and the years or periods you list on Form
8821. You may file your own tax information authorization
without using Form 8821, but it must include all the
information that is requested on Form 8821.
Form 8821 does not authorize your appointee to
advocate your position with respect to the federal tax laws;
to execute waivers, consents, or closing agreements; or to
otherwise represent you before the IRS. If you want to
authorize an individual to represent you, use Form 2848,
Power of Attorney and Declaration of Representative.
Use Form 4506, Request for Copy of Tax Return, to get a
copy of your tax return.
Use Form 4506-T, Request for Transcript of Tax Return,
to order: (a) transcript of tax account information and (b)
Form W-2 and Form 1099 series information.
Use Form 56, Notice Concerning Fiduciary Relationship,
to notify the IRS of the existence of a fiduciary relationship.
A fiduciary (trustee, executor, administrator, receiver, or
guardian) stands in the position of a taxpayer and acts as
the taxpayer. Therefore, a fiduciary does not act as an
appointee and should not file Form 8821. If a fiduciary
wishes to authorize an appointee to inspect and/or receive
confidential tax information on behalf of the fiduciary, Form
8821 must be filed and signed by the fiduciary acting in the
position of the taxpayer.
When To File
Form 8821 must be received by the IRS within 120 days of
the date it was signed and dated by the taxpayer.
Where To File Chart
IF you live in . . .
Page 2
Form 8821 (Rev. 10-2011)
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
What's New
Appointees will no longer receive inserts, such as forms,
publications, and other related materials, with notices.
Purpose of Form
Form 8821 authorizes any individual, corporation, firm,
organization, or partnership you designate to inspect and/or
receive your confidential information in any office of the IRS
for the type of tax and the years or periods you list on Form
8821. You may file your own tax information authorization
without using Form 8821, but it must include all the
information that is requested on Form 8821.
Form 8821 does not authorize your appointee to
advocate your position with respect to the federal tax laws;
to execute waivers, consents, or closing agreements; or to
otherwise represent you before the IRS. If you want to
authorize an individual to represent you, use Form 2848,
Power of Attorney and Declaration of Representative.
Use Form 4506, Request for Copy of Tax Return, to get a
copy of your tax return.
Use Form 4506-T, Request for Transcript of Tax Return,
to order: (a) transcript of tax account information and (b)
Form W-2 and Form 1099 series information.
Use Form 56, Notice Concerning Fiduciary Relationship,
to notify the IRS of the existence of a fiduciary relationship.
A fiduciary (trustee, executor, administrator, receiver, or
guardian) stands in the position of a taxpayer and acts as
the taxpayer. Therefore, a fiduciary does not act as an
appointee and should not file Form 8821. If a fiduciary
wishes to authorize an appointee to inspect and/or receive
confidential tax information on behalf of the fiduciary, Form
8821 must be filed and signed by the fiduciary acting in the
position of the taxpayer.
When To File
Form 8821 must be received by the IRS within 120 days of
the date it was signed and dated by the taxpayer.
Where To File Chart
THEN use this address . . .
Fax Number*
IF you live in . . .
THEN use this address . . .
Fax Number*
Alabama, Arkansas, Connecticut, Delaware, District
of Columbia, Florida, Georgia, Illinois, Indiana,
Kentucky, Louisiana, Maine, Maryland,
Massachusetts, Michigan, Mississippi, New
Hampshire, New Jersey, New York, North Carolina,
Ohio, Pennsylvania, Rhode Island, South Carolina,
Tennessee, Vermont, Virginia, or West Virginia
Internal Revenue Service
Memphis Accounts Management Center
PO Box 268, Stop 8423
Memphis, TN 38101-0268
901-546-4115
Alabama, Arkansas, Connecticut, Delaware, District
of Columbia, Florida, Georgia, Illinois, Indiana,
Kentucky, Louisiana, Maine, Maryland,
Massachusetts, Michigan, Mississippi, New
Hampshire, New Jersey, New York, North Carolina,
Ohio, Pennsylvania, Rhode Island, South Carolina,
Tennessee, Vermont, Virginia, or West Virginia
Internal Revenue Service
Memphis Accounts Management Center
PO Box 268, Stop 8423
Memphis, TN 38101-0268
901-546-4115
Alaska, Arizona, California, Colorado, Hawaii, Idaho,
Iowa, Kansas, Minnesota, Missouri, Montana,
Nebraska, Nevada, New Mexico, North Dakota,
Oklahoma, Oregon, South Dakota, Texas, Utah,
Washington, Wisconsin, or Wyoming
Internal Revenue Service
1973 N. Rulon White Blvd. MS 6737
Ogden, UT 84404
801-620-4249
Alaska, Arizona, California, Colorado, Hawaii, Idaho,
Iowa, Kansas, Minnesota, Missouri, Montana,
Nebraska, Nevada, New Mexico, North Dakota,
Oklahoma, Oregon, South Dakota, Texas, Utah,
Washington, Wisconsin, or Wyoming
Internal Revenue Service
1973 N. Rulon White Blvd. MS 6737
Ogden, UT 84404
801-620-4249
All APO and FPO addresses, American Samoa,
nonpermanent residents of Guam or the Virgin
Islands**, Puerto Rico (or if excluding income under
section 933), a foreign country, U.S. citizens and
those filing Form 2555, 2555-EZ, or 4563.
Internal Revenue Service
International CAF
2970 Market St. MS 3-E08.123
Philadelphia, PA 19104
267-941-1017
All APO and FPO addresses, American Samoa,
nonpermanent residents of Guam or the Virgin
Islands**, Puerto Rico (or if excluding income under
section 933), a foreign country, U.S. citizens and
those filing Form 2555, 2555-EZ, or 4563.
Internal Revenue Service
International CAF
2970 Market St. MS 3-E08.123
Philadelphia, PA 19104
267-941-1017
*These numbers may change without notice.
**Permanent residents of Guam should use Department of Taxation, Government of Guam, P.O. Box 23607, GMF, GU
96921; permanent residents of the Virgin Islands should use: V.I. Bureau of Internal Revenue, 9601 Estate Thomas
Charlotte Amalie, St. Thomas, V.I. 00802.
*These numbers may change without notice.
**Permanent residents of Guam should use Department of Taxation, Government of Guam, P.O. Box 23607, GMF, GU
96921; permanent residents of the Virgin Islands should use: V.I. Bureau of Internal Revenue, 9601 Estate Thomas
Charlotte Amalie, St. Thomas, V.I. 00802.
Page 3
Form 8821 (Rev. 10-2011)
Where To File
Generally, mail or fax Form 8821 directly to the IRS. See the
Where To File Chart, above. Exceptions are listed below.
If Form 8821 is for a specific tax matter, mail or fax it to
the office handling that matter. For more information, see the
instructions for line 4.
Your appointee may be able to file Form 8821
electronically with the IRS from the IRS website. For more
information, go to www.irs.gov. Under the Tax Professionals
tab, click on e-services–Online Tools for Tax Professionals. If
you complete Form 8821 for electronic signature
authorization, do not file a Form 8821 with the IRS. Instead,
give it to your appointee, who will retain the document.
Revocation of an Existing Tax Information
Authorization
If you want to revoke an existing tax information
authorization and do not want to name a new appointee,
send a copy of the previously executed tax information
authorization to the IRS, using the Where To File Chart,
above. The copy of the tax information authorization must
have a current signature and date of the taxpayer under the
original signature on line 7. Write “REVOKE” across the top
of Form 8821.
Specific Instructions
Where To File
Specific Instructions
Line 1. Taxpayer Information
Generally, mail or fax Form 8821 directly to the IRS. See the
Where To File Chart, above. Exceptions are listed below.
If Form 8821 is for a specific tax matter, mail or fax it to
the office handling that matter. For more information, see the
instructions for line 4.
Your appointee may be able to file Form 8821
electronically with the IRS from the IRS website. For more
information, go to www.irs.gov. Under the Tax Professionals
tab, click on e-services–Online Tools for Tax Professionals. If
you complete Form 8821 for electronic signature
authorization, do not file a Form 8821 with the IRS. Instead,
give it to your appointee, who will retain the document.
Line 1. Taxpayer Information
Individuals. Enter your name, TIN, and your street
address in the space provided. Do not enter your
appointee’s address or post office box. If a joint return is
used, also enter your spouse’s name and TIN. Also enter
your EIN if applicable.
Corporations, partnerships, or associations. Enter the
name, EIN, and business address.
Employee plan or exempt organization. Enter the name,
address, and EIN of the plan sponsor or exempt
organization, and the plan name and three-digit plan
number.
Trust. Enter the name, title, and address of the trustee,
and the name and EIN of the trust.
Estate. Enter the name, title, and address of the
decedent’s executor/personal representative, and the name
and identification number of the estate. The identification
number for an estate includes both the EIN, if the estate has
one, and the decedent’s TIN.
Line 2. Appointee
To revoke a specific use tax information authorization,
send the tax information authorization or statement of
revocation to the IRS office handling your case, using the
above instructions.
Enter your appointee’s full name. Use the identical full name
on all submissions and correspondence. Enter the nine-digit
CAF number for each appointee. If an appointee has a CAF
number for any previously filed Form 8821 or power of
attorney (Form 2848), use that number. If a CAF number has
not been assigned, enter “NONE,” and the IRS will issue one
directly to your appointee. The IRS does not assign CAF
numbers to requests for employee plans and exempt
organizations.
If you want to name more than one appointee, indicate so
on this line and attach a list of appointees to Form 8821.
Check the appropriate box to indicate if either the
address, telephone number, or fax number is new since a
CAF number was assigned.
Taxpayer Identification Numbers (TINs)
If you do not have a copy of the tax information
authorization you want to revoke, send a statement to the
IRS. In the statement, indicate that the authority of the
appointee is revoked, list the name and address of each
recognized appointee whose authority is revoked, list the
tax matters and periods, and sign and date the statement. If
you are completely revoking the authority of the appointee,
state “remove all years/periods” instead of listing the
specific tax matters, years, or periods on the form.
TINs are used to identify taxpayer information with
corresponding tax returns. It is important that you furnish
correct names, social security numbers (SSNs), individual
taxpayer identification numbers (ITINs), or employer
identification numbers (EINs) so that the IRS can respond to
your request.
Partnership Items
Sections 6221-6234 authorize a Tax Matters Partner to
perform certain acts on behalf of an affected partnership.
Rules governing the use of Form 8821 do not replace any
provisions of these sections.
Appointee Address Change
If the appointee's address has changed, a new Form 8821
is not required. The appointee can send a written
notification that includes the new information and their
signature to the location where the Form 8821 was filed.
Page 3
Form 8821 (Rev. 10-2011)
Revocation of an Existing Tax Information
Authorization
If you want to revoke an existing tax information
authorization and do not want to name a new appointee,
send a copy of the previously executed tax information
authorization to the IRS, using the Where To File Chart,
above. The copy of the tax information authorization must
have a current signature and date of the taxpayer under the
original signature on line 7. Write “REVOKE” across the top
of Form 8821.
Individuals. Enter your name, TIN, and your street
address in the space provided. Do not enter your
appointee’s address or post office box. If a joint return is
used, also enter your spouse’s name and TIN. Also enter
your EIN if applicable.
Corporations, partnerships, or associations. Enter the
name, EIN, and business address.
Employee plan or exempt organization. Enter the name,
address, and EIN of the plan sponsor or exempt
organization, and the plan name and three-digit plan
number.
Trust. Enter the name, title, and address of the trustee,
and the name and EIN of the trust.
Estate. Enter the name, title, and address of the
decedent’s executor/personal representative, and the name
and identification number of the estate. The identification
number for an estate includes both the EIN, if the estate has
one, and the decedent’s TIN.
Line 2. Appointee
To revoke a specific use tax information authorization,
send the tax information authorization or statement of
revocation to the IRS office handling your case, using the
above instructions.
Enter your appointee’s full name. Use the identical full name
on all submissions and correspondence. Enter the nine-digit
CAF number for each appointee. If an appointee has a CAF
number for any previously filed Form 8821 or power of
attorney (Form 2848), use that number. If a CAF number has
not been assigned, enter “NONE,” and the IRS will issue one
directly to your appointee. The IRS does not assign CAF
numbers to requests for employee plans and exempt
organizations.
If you want to name more than one appointee, indicate so
on this line and attach a list of appointees to Form 8821.
Check the appropriate box to indicate if either the
address, telephone number, or fax number is new since a
CAF number was assigned.
Line 3. Matters
Taxpayer Identification Numbers (TINs)
Line 3. Matters
Enter the type of tax, the tax form number, the years or
periods, and the specific matter. Enter “Not applicable,” in
any of the columns that do not apply.
For example, you may list “Income, 1040” for calendar
year “2006” and “Excise, 720” for “2006” (this covers all
quarters in 2006). For multiple years or a series of inclusive
periods, including quarterly periods, you may list 2004
through (thru or a hyphen) 2006. For example, “2004 thru
2006” or “2nd 2005-3rd 2006.” For fiscal years, enter the
ending year and month, using the YYYYMM format. Do not
use a general reference such as “All years,” “All periods,” or
“All taxes.” Any tax information authorization with a general
reference will be returned.
You may list the current year or period and any tax years
or periods that have already ended as of the date you sign
the tax information authorization. However, you may include
on a tax information authorization only future tax periods that
end no later than 3 years after the date the tax information
authorization is received by the IRS. The 3 future periods are
determined starting after December 31 of the year the tax
information authorization is received by the IRS. You must
enter the type of tax, the tax form number, and the future
year(s) or period(s). If the matter relates to estate tax, enter
the date of the decedent’s death instead of the year or
period.
TINs are used to identify taxpayer information with
corresponding tax returns. It is important that you furnish
correct names, social security numbers (SSNs), individual
taxpayer identification numbers (ITINs), or employer
identification numbers (EINs) so that the IRS can respond to
your request.
Enter the type of tax, the tax form number, the years or
periods, and the specific matter. Enter “Not applicable,” in
any of the columns that do not apply.
For example, you may list “Income, 1040” for calendar
year “2006” and “Excise, 720” for “2006” (this covers all
quarters in 2006). For multiple years or a series of inclusive
periods, including quarterly periods, you may list 2004
through (thru or a hyphen) 2006. For example, “2004 thru
2006” or “2nd 2005-3rd 2006.” For fiscal years, enter the
ending year and month, using the YYYYMM format. Do not
use a general reference such as “All years,” “All periods,” or
“All taxes.” Any tax information authorization with a general
reference will be returned.
You may list the current year or period and any tax years
or periods that have already ended as of the date you sign
the tax information authorization. However, you may include
on a tax information authorization only future tax periods that
end no later than 3 years after the date the tax information
authorization is received by the IRS. The 3 future periods are
determined starting after December 31 of the year the tax
information authorization is received by the IRS. You must
enter the type of tax, the tax form number, and the future
year(s) or period(s). If the matter relates to estate tax, enter
the date of the decedent’s death instead of the year or
period.
If you do not have a copy of the tax information
authorization you want to revoke, send a statement to the
IRS. In the statement, indicate that the authority of the
appointee is revoked, list the name and address of each
recognized appointee whose authority is revoked, list the
tax matters and periods, and sign and date the statement. If
you are completely revoking the authority of the appointee,
state “remove all years/periods” instead of listing the
specific tax matters, years, or periods on the form.
Partnership Items
Sections 6221-6234 authorize a Tax Matters Partner to
perform certain acts on behalf of an affected partnership.
Rules governing the use of Form 8821 do not replace any
provisions of these sections.
Appointee Address Change
If the appointee's address has changed, a new Form 8821
is not required. The appointee can send a written
notification that includes the new information and their
signature to the location where the Form 8821 was filed.
Form 8821 (Rev. 10-2011)
In column (d), enter any specific information you want the
IRS to provide. Examples of column (d) information are: lien
information, a balance due amount, a specific tax schedule,
or a tax liability.
For requests regarding Form 8802, Application for United
States Residency Certification, enter “Form 8802” in column
(d) and check the specific use box on line 4. Also, enter the
appointee’s information as instructed on Form 8802.
Note. If the taxpayer is subject to penalties related to an
individual retirement account (IRA) (for example, a penalty
for excess contributions) enter, “IRA civil penalty” on line 3,
column a.
Line 4. Specific Use Not Recorded on CAF
Generally, the IRS records all tax information authorizations
on the CAF system. However, authorizations relating to a
specific issue are not recorded.
Check the box on line 4 if Form 8821 is filed for any of the
following reasons: (a) requests to disclose information to
loan companies or educational institutions, (b) requests to
disclose information to federal or state agency investigators
for background checks, (c) application for EIN, or (d) claims
filed on Form 843, Claim for Refund and Request for
Abatement. If you check the box on line 4, your appointee
should mail or fax Form 8821 to the IRS office handling the
matter. Otherwise, your appointee should bring a copy of
Form 8821 to each appointment to inspect or receive
information. A specific-use tax information authorization will
not revoke any prior tax information authorizations.
Line 6. Retention/Revocation of Tax
Information Authorizations
Check the box on this line and attach a copy of the tax
information authorization you do not want to revoke. The
filing of Form 8821 will not revoke any Form 2848 that is in
effect.
Line 7. Signature of Taxpayer(s)
Individuals. You must sign and date the authorization.
Either husband or wife must sign if Form 8821 applies to a
joint return.
Corporations. Generally, Form 8821 can be signed by: (a)
an officer having legal authority to bind the corporation, (b)
any person designated by the board of directors or other
governing body, (c) any officer or employee on written
request by any principal officer and attested to by the
secretary or other officer, and (d) any other person
authorized to access information under section 6103(e).
Partnerships. Generally, Form 8821 can be signed by any
person who was a member of the partnership during any
part of the tax period covered by Form 8821. See
Partnership Items, above.
Page 4
All others. See section 6103(e) if the taxpayer has died, is
insolvent, is a dissolved corporation, or if a trustee, guardian,
executor, receiver, or administrator is acting for the taxpayer.
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. Form 8821
authorizes the IRS to disclose your confidential tax
information to the person you appoint. This form is provided
for your convenience and its use is voluntary. The
information is used by the IRS to determine what confidential
tax information your appointee can inspect and/or receive.
Section 6103(c) and its regulations require you to provide
this information if you want to designate an appointee to
inspect and/or receive your confidential tax information.
Under section 6109, you must disclose your identification
number. If you do not provide all the information requested
on this form, we may not be able to honor the authorization.
Providing false or fraudulent information may subject you to
penalties.
We may disclose this information to the Department of
Justice for civil or criminal litigation, and to cities, states, the
District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws. We may
also disclose this information to other countries under a tax
treaty, to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
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.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated
average time is: Recordkeeping, 6 min.; Learning about
the law or the form, 12 min.; Preparing the form, 24 min.;
Copying and sending the form to the IRS, 20 min.
If you have comments concerning the accuracy of these
time estimates or suggestions for making Form 8821
simpler, we would be happy to hear from you. You can write
to Internal Revenue Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:M:S, 1111 Constitution Ave.
NW, IR-6526, Washington, DC 20224. Do not send Form
8821 to this address. Instead, see the Where To File Chart
earlier.
Form 8821 (Rev. 10-2011)
In column (d), enter any specific information you want the
IRS to provide. Examples of column (d) information are: lien
information, a balance due amount, a specific tax schedule,
or a tax liability.
For requests regarding Form 8802, Application for United
States Residency Certification, enter “Form 8802” in column
(d) and check the specific use box on line 4. Also, enter the
appointee’s information as instructed on Form 8802.
Note. If the taxpayer is subject to penalties related to an
individual retirement account (IRA) (for example, a penalty
for excess contributions) enter, “IRA civil penalty” on line 3,
column a.
Line 4. Specific Use Not Recorded on CAF
Generally, the IRS records all tax information authorizations
on the CAF system. However, authorizations relating to a
specific issue are not recorded.
Check the box on line 4 if Form 8821 is filed for any of the
following reasons: (a) requests to disclose information to
loan companies or educational institutions, (b) requests to
disclose information to federal or state agency investigators
for background checks, (c) application for EIN, or (d) claims
filed on Form 843, Claim for Refund and Request for
Abatement. If you check the box on line 4, your appointee
should mail or fax Form 8821 to the IRS office handling the
matter. Otherwise, your appointee should bring a copy of
Form 8821 to each appointment to inspect or receive
information. A specific-use tax information authorization will
not revoke any prior tax information authorizations.
Line 6. Retention/Revocation of Tax
Information Authorizations
Check the box on this line and attach a copy of the tax
information authorization you do not want to revoke. The
filing of Form 8821 will not revoke any Form 2848 that is in
effect.
Line 7. Signature of Taxpayer(s)
Individuals. You must sign and date the authorization.
Either husband or wife must sign if Form 8821 applies to a
joint return.
Corporations. Generally, Form 8821 can be signed by: (a)
an officer having legal authority to bind the corporation, (b)
any person designated by the board of directors or other
governing body, (c) any officer or employee on written
request by any principal officer and attested to by the
secretary or other officer, and (d) any other person
authorized to access information under section 6103(e).
Partnerships. Generally, Form 8821 can be signed by any
person who was a member of the partnership during any
part of the tax period covered by Form 8821. See
Partnership Items, above.
Page 4
All others. See section 6103(e) if the taxpayer has died, is
insolvent, is a dissolved corporation, or if a trustee, guardian,
executor, receiver, or administrator is acting for the taxpayer.
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. Form 8821
authorizes the IRS to disclose your confidential tax
information to the person you appoint. This form is provided
for your convenience and its use is voluntary. The
information is used by the IRS to determine what confidential
tax information your appointee can inspect and/or receive.
Section 6103(c) and its regulations require you to provide
this information if you want to designate an appointee to
inspect and/or receive your confidential tax information.
Under section 6109, you must disclose your identification
number. If you do not provide all the information requested
on this form, we may not be able to honor the authorization.
Providing false or fraudulent information may subject you to
penalties.
We may disclose this information to the Department of
Justice for civil or criminal litigation, and to cities, states, the
District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws. We may
also disclose this information to other countries under a tax
treaty, to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
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.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated
average time is: Recordkeeping, 6 min.; Learning about
the law or the form, 12 min.; Preparing the form, 24 min.;
Copying and sending the form to the IRS, 20 min.
If you have comments concerning the accuracy of these
time estimates or suggestions for making Form 8821
simpler, we would be happy to hear from you. You can write
to Internal Revenue Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:M:S, 1111 Constitution Ave.
NW, IR-6526, Washington, DC 20224. Do not send Form
8821 to this address. Instead, see the Where To File Chart
earlier.
SS-4
Application for Employer Identification Number
(Rev. January 2010)
Type or print clearly.
Department of the Treasury
Internal Revenue Service
8a
8c
9a
(For use by employers, corporations, partnerships, trusts, estates, churches,
government agencies, Indian tribal entities, certain individuals, and others.)
10
Form
Keep a copy for your records.
2
Trade name of business (if different from name on line 1)
3
Executor, administrator, trustee, “care of” name
4a
Mailing address (room, apt., suite no. and street, or P.O. box)
5a
Street address (if different) (Do not enter a P.O. box.)
,HHCSR
P.O. Box 2130
City, state, and ZIP code (if foreign, see instructions)
5b
City, state, and ZIP code (if foreign, see instructions)
Amherst, MA 01004
6
County and state where principal business is located
7a
Name of responsible party
Is this application for a limited liability company (LLC) (or
a foreign equivalent)?
7b
SSN, ITIN, or EIN
8b
If 8a is “Yes,” enter the number of
LLC members
✔ No
Yes
Application for Employer Identification Number
Department of the Treasury
Internal Revenue Service
Legal name of entity (or individual) for whom the EIN is being requested
4b
SS-4
(Rev. January 2010)
1
8a
✔ No
Yes
If 8a is “Yes,” was the LLC organized in the United States?
Type of entity (check only one box). Caution. If 8a is “Yes,” see the instructions for the correct box to check.
8c
9a
(For use by employers, corporations, partnerships, trusts, estates, churches,
government agencies, Indian tribal entities, certain individuals, and others.)
2
Trade name of business (if different from name on line 1)
3
Executor, administrator, trustee, “care of” name
4a
Mailing address (room, apt., suite no. and street, or P.O. box)
5a
Street address (if different) (Do not enter a P.O. box.)
5b
City, state, and ZIP code (if foreign, see instructions)
,HHCSR
P.O. Box 2130
4b
City, state, and ZIP code (if foreign, see instructions)
Amherst, MA 01004
6
County and state where principal business is located
7a
Name of responsible party
Is this application for a limited liability company (LLC) (or
a foreign equivalent)?
Sole proprietor (SSN)
Plan administrator (TIN)
Partnership
Trust (TIN of grantor)
Corporation (enter form number to be filed)
Estate (SSN of decedent)
Plan administrator (TIN)
Trust (TIN of grantor)
National Guard
State/local government
Church or church-controlled organization
Farmers’ cooperative
Federal government/military
Church or church-controlled organization
Farmers’ cooperative
Federal government/military
Other nonprofit organization (specify) ✔ Other (specify) HHCSR
If a corporation, name the state or foreign country
(if applicable) where incorporated
Reason for applying (check only one box)
State
REMIC
Indian tribal governments/enterprises
Group Exemption Number (GEN) if any Foreign country
Banking purpose (specify purpose)
9b
10
Changed type of organization (specify new type)
Other nonprofit organization (specify) ✔ Other (specify) HHCSR
If a corporation, name the state or foreign country
(if applicable) where incorporated
Reason for applying (check only one box)
Started new business (specify type)
Created a trust (specify type)
Hired employees (Check the box and see line 13.)
December
If you expect your employment tax liability to be $1,000
Highest number of employees expected in the next 12 months (enter -0- if none).
or less in a full calendar year and want to file Form 944
annually instead of Forms 941 quarterly, check here.
If no employees expected, skip line 14.
(Your employment tax liability generally will be $1,000
or less if you expect to pay $4,000 or less in total
Agricultural
Household
Other
wages.) If you do not check this box, you must file
0
0
0
Form 941 for every quarter.
First date wages or annuities were paid (month, day, year). Note. If applicant is a withholding agent, enter date income will first be paid to
nonresident alien (month, day, year)
N/A
Check one box that best describes the principal activity of your business.
Rental & leasing
Health care & social assistance
Accommodation & food service
Wholesale-agent/broker
Retail
Wholesale-other
Transportation & warehousing
Finance & insurance
✔ Other (specify) HHCSR
Real estate
Manufacturing
Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.
Banking purpose (specify purpose)
Changed type of organization (specify new type)
11
Created a trust (specify type)
Compliance with IRS withholding regulations
Created a pension plan (specify type) ✔ Other (specify) HHCSR
Date business started or acquired (month, day, year). See instructions.
12 Closing month of accounting year
December
If you expect your employment tax liability to be $1,000
Highest number of employees expected in the next 12 months (enter -0- if none).
or less in a full calendar year and want to file Form 944
annually instead of Forms 941 quarterly, check here.
If no employees expected, skip line 14.
(Your employment tax liability generally will be $1,000
or less if you expect to pay $4,000 or less in total
Agricultural
Household
Other
wages.) If you do not check this box, you must file
0
0
0
Form 941 for every quarter.
First date wages or annuities were paid (month, day, year). Note. If applicant is a withholding agent, enter date income will first be paid to
nonresident alien (month, day, year)
N/A
14
13
15
16
Check one box that best describes the principal activity of your business.
Health care & social assistance
Wholesale-agent/broker
Accommodation & food service
Retail
Transportation & warehousing
Wholesale-other
Finance
&
insurance
✔
Real estate
Manufacturing
Other (specify) HHCSR
Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided.
Construction
17
Yes
✔ No
18
Rental & leasing
Has the applicant entity shown on line 1 ever applied for and received an EIN?
If “Yes,” write previous EIN here Complete this section only if you want to authorize the named individual to receive the entity’s EIN and answer questions about the completion of this form.
Designee’s name
Designee’s telephone number (include area code)
Seren Derin, Stavros Ctr For Ind Liv Inc.
( 413 )
Address and ZIP code
P.O. Box 2130, Amherst, MA 01002
Name and title (type or print clearly)
256-6692
Designee’s fax number (include area code)
( 413 )
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.
(
)
✔ No
Complete this section only if you want to authorize the named individual to receive the entity’s EIN and answer questions about the completion of this form.
Third
Party
Designee
256-3516
Applicant’s telephone number (include area code)
Yes
Designee’s name
Designee’s telephone number (include area code)
Seren Derin, Stavros Ctr For Ind Liv Inc.
( 413 )
Address and ZIP code
P.O. Box 2130, Amherst, MA 01002
( 413 )
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete.
Name and title (type or print clearly)
Date
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
(
Cat. No. 16055N
)
Form
(Rev. 1-2010)
256-3516
Applicant’s telephone number (include area code)
(
)
Applicant’s fax number (include area code)
Signature
SS-4
256-6692
Designee’s fax number (include area code)
Applicant’s fax number (include area code)
HHCSR
Has the applicant entity shown on line 1 ever applied for and received an EIN?
If “Yes,” write previous EIN here Third
Party
Designee
State
REMIC
Indian tribal governments/enterprises
Group Exemption Number (GEN) if any Foreign country
Purchased going business
Compliance with IRS withholding regulations
Created a pension plan (specify type) ✔ Other (specify) HHCSR
Date business started or acquired (month, day, year). See instructions.
12 Closing month of accounting year
Signature
✔ No
Yes
Personal service corporation
HHCSR
18
If 8a is “Yes,” enter the number of
LLC members
State/local government
Construction
17
8b
✔ No
Yes
National Guard
14
16
SSN, ITIN, or EIN
Personal service corporation
Hired employees (Check the box and see line 13.)
15
7b
If 8a is “Yes,” was the LLC organized in the United States?
Type of entity (check only one box). Caution. If 8a is “Yes,” see the instructions for the correct box to check.
Purchased going business
13
Keep a copy for your records.
Legal name of entity (or individual) for whom the EIN is being requested
Estate (SSN of decedent)
Started new business (specify type)
11
OMB No. 1545-0003
EIN
1
Partnership
See separate instructions for each line.
Sole proprietor (SSN)
Corporation (enter form number to be filed)
9b
See separate instructions for each line.
OMB No. 1545-0003
EIN
Type or print clearly.
Form
Date
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
(
Cat. No. 16055N
)
Form
SS-4
(Rev. 1-2010)
Form SS-4 (Rev. 1-2010)
Page
2
Form SS-4 (Rev. 1-2010)
Page
Do I Need an EIN?
Do I Need an EIN?
File Form SS-4 if the applicant entity does not already have an EIN but is required to show an EIN on any return, statement,
or other document.1 See also the separate instructions for each line on Form SS-4.
IF the applicant...
Started a new business
AND...
Hired (or will hire) employees,
including household employees
File Form SS-4 if the applicant entity does not already have an EIN but is required to show an EIN on any return, statement,
or other document.1 See also the separate instructions for each line on Form SS-4.
THEN...
Complete lines 1, 2, 4a–8a, 8b–c (if applicable), 9a,
9b (if applicable), and 10–14 and 16–18.
IF the applicant...
Started a new business
AND...
Does not already have an EIN
Complete lines 1, 2, 4a–6, 7a–b (if applicable), 8a,
8b–c (if applicable), 9a, 9b (if applicable), 10–18.
Hired (or will hire) employees,
including household employees
Does not already have an EIN
Complete lines 1, 2, 4a–6, 7a–b (if applicable), 8a,
8b–c (if applicable), 9a, 9b (if applicable), 10–18.
Opened a bank account
Needs an EIN for banking purposes only
Complete lines 1–5b, 7a–b (if applicable), 8a, 8b–c
(if applicable), 9a, 9b (if applicable), 10, and 18.
Opened a bank account
Needs an EIN for banking purposes only
Complete lines 1–5b, 7a–b (if applicable), 8a, 8b–c
(if applicable), 9a, 9b (if applicable), 10, and 18.
Changed type of organization
Either the legal character of the organization or its
ownership changed (for example, you incorporate a
sole proprietorship or form a partnership) 2
Complete lines 1–18 (as applicable).
Changed type of organization
Either the legal character of the organization or its
ownership changed (for example, you incorporate a
sole proprietorship or form a partnership) 2
Complete lines 1–18 (as applicable).
Purchased a going business 3
Created a trust
Does not already have an EIN
The trust is other than a grantor trust or an IRA
trust 4
Complete lines 1–18 (as applicable).
Complete lines 1–18 (as applicable).
Purchased a going business 3
Created a trust
Does not already have an EIN
The trust is other than a grantor trust or an IRA
trust 4
Complete lines 1–18 (as applicable).
Complete lines 1–18 (as applicable).
Created a pension plan as a
plan administrator 5
Needs an EIN for reporting purposes
Complete lines 1, 3, 4a–5b, 9a, 10, and 18.
Created a pension plan as a
plan administrator 5
Needs an EIN for reporting purposes
Complete lines 1, 3, 4a–5b, 9a, 10, and 18.
Is a foreign person needing an
EIN to comply with IRS
withholding regulations
Needs an EIN to complete a Form W-8 (other than
Form W-8ECI), avoid withholding on portfolio assets,
or claim tax treaty benefits 6
Complete lines 1–5b, 7a–b (SSN or ITIN optional),
8a, 8b–c (if applicable), 9a, 9b (if applicable), 10,
and 18.
Is a foreign person needing an
EIN to comply with IRS
withholding regulations
Needs an EIN to complete a Form W-8 (other than
Form W-8ECI), avoid withholding on portfolio assets,
or claim tax treaty benefits 6
Complete lines 1–5b, 7a–b (SSN or ITIN optional),
8a, 8b–c (if applicable), 9a, 9b (if applicable), 10,
and 18.
Is administering an estate
Needs an EIN to report estate income on Form 1041
Complete lines 1–6, 9a, 10–12, 13–17 (if applicable),
and 18.
Is administering an estate
Needs an EIN to report estate income on Form 1041
Complete lines 1–6, 9a, 10–12, 13–17 (if applicable),
and 18.
Is a withholding agent for
taxes on non-wage income
paid to an alien (i.e.,
individual, corporation, or
partnership, etc.)
Is a state or local agency
Is an agent, broker, fiduciary, manager, tenant, or
spouse who is required to file Form 1042, Annual
Withholding Tax Return for U.S. Source Income of
Foreign Persons
Complete lines 1, 2, 3 (if applicable), 4a–5b, 7a–b (if
applicable), 8a, 8b–c (if applicable), 9a, 9b (if
applicable), 10, and 18.
Is an agent, broker, fiduciary, manager, tenant, or
spouse who is required to file Form 1042, Annual
Withholding Tax Return for U.S. Source Income of
Foreign Persons
Complete lines 1, 2, 3 (if applicable), 4a–5b, 7a–b (if
applicable), 8a, 8b–c (if applicable), 9a, 9b (if
applicable), 10, and 18.
Serves as a tax reporting agent for public assistance
recipients under Rev. Proc. 80-4, 1980-1 C.B. 581 7
Complete lines 1, 2, 4a–5b, 9a, 10, and 18.
Is a withholding agent for
taxes on non-wage income
paid to an alien (i.e.,
individual, corporation, or
partnership, etc.)
Is a state or local agency
Serves as a tax reporting agent for public assistance
recipients under Rev. Proc. 80-4, 1980-1 C.B. 581 7
Complete lines 1, 2, 4a–5b, 9a, 10, and 18.
Is a single-member LLC
Needs an EIN to file Form 8832, Classification
Election, for filing employment tax returns and
excise tax returns, or for state reporting purposes 8
Complete lines 1–18 (as applicable).
Is a single-member LLC
Needs an EIN to file Form 8832, Classification
Election, for filing employment tax returns and
excise tax returns, or for state reporting purposes 8
Complete lines 1–18 (as applicable).
Is an S corporation
Needs an EIN to file Form 2553, Election by a Small
Business Corporation 9
Complete lines 1–18 (as applicable).
Is an S corporation
Needs an EIN to file Form 2553, Election by a Small
Business Corporation 9
Complete lines 1–18 (as applicable).
Does not currently have (nor expect to have)
employees
Does not currently have (nor expect to have)
employees
THEN...
Complete lines 1, 2, 4a–8a, 8b–c (if applicable), 9a,
9b (if applicable), and 10–14 and 16–18.
1
For example, a sole proprietorship or self-employed farmer who establishes a qualified retirement plan, or is required to file excise, employment, alcohol,
tobacco, or firearms returns, must have an EIN. A partnership, corporation, REMIC (real estate mortgage investment conduit), nonprofit organization
(church, club, etc.), or farmers’ cooperative must use an EIN for any tax-related purpose even if the entity does not have employees.
1
For example, a sole proprietorship or self-employed farmer who establishes a qualified retirement plan, or is required to file excise, employment, alcohol,
tobacco, or firearms returns, must have an EIN. A partnership, corporation, REMIC (real estate mortgage investment conduit), nonprofit organization
(church, club, etc.), or farmers’ cooperative must use an EIN for any tax-related purpose even if the entity does not have employees.
2
However, do not apply for a new EIN if the existing entity only (a) changed its business name, (b) elected on Form 8832 to change the way it is taxed (or is
covered by the default rules), or (c) terminated its partnership status because at least 50% of the total interests in partnership capital and profits were sold or
exchanged within a 12-month period. The EIN of the terminated partnership should continue to be used. See Regulations section 301.6109-1(d)(2)(iii).
Do not use the EIN of the prior business unless you became the “owner” of a corporation by acquiring its stock.
2
However, do not apply for a new EIN if the existing entity only (a) changed its business name, (b) elected on Form 8832 to change the way it is taxed (or is
covered by the default rules), or (c) terminated its partnership status because at least 50% of the total interests in partnership capital and profits were sold or
exchanged within a 12-month period. The EIN of the terminated partnership should continue to be used. See Regulations section 301.6109-1(d)(2)(iii).
Do not use the EIN of the prior business unless you became the “owner” of a corporation by acquiring its stock.
4
However, grantor trusts that do not file using Optional Method 1 and IRA trusts that are required to file Form 990-T, Exempt Organization Business Income Tax
Return, must have an EIN. For more information on grantor trusts, see the Instructions for Form 1041.
4
However, grantor trusts that do not file using Optional Method 1 and IRA trusts that are required to file Form 990-T, Exempt Organization Business Income Tax
Return, must have an EIN. For more information on grantor trusts, see the Instructions for Form 1041.
5
A plan administrator is the person or group of persons specified as the administrator by the instrument under which the plan is operated.
5
A plan administrator is the person or group of persons specified as the administrator by the instrument under which the plan is operated.
6
Entities applying to be a Qualified Intermediary (QI) need a QI-EIN even if they already have an EIN. See Rev. Proc. 2000-12.
6
Entities applying to be a Qualified Intermediary (QI) need a QI-EIN even if they already have an EIN. See Rev. Proc. 2000-12.
7
See also Household employer on page 4 of the instructions. Note. State or local agencies may need an EIN for other reasons, for example, hired employees.
7
See also Household employer on page 4 of the instructions. Note. State or local agencies may need an EIN for other reasons, for example, hired employees.
8
See Disregarded entities on page 4 of the instructions for details on completing Form SS-4 for an LLC.
8
See Disregarded entities on page 4 of the instructions for details on completing Form SS-4 for an LLC.
9
An existing corporation that is electing or revoking S corporation status should use its previously-assigned EIN.
9
An existing corporation that is electing or revoking S corporation status should use its previously-assigned EIN.
3
3
2
Form
2678
(Rev. June 2011)
Employer/Payer Appointment of Agent
OMB No. 1545-0748
Department of the Treasury — Internal Revenue Service
Use this form if you want to request approval to have an agent file returns and make
deposits or payments of employment or other withholding taxes or if you want to
revoke an existing appointment.
Form
2678
(Rev. June 2011)
Employer/Payer Appointment of Agent
OMB No. 1545-0748
Department of the Treasury — Internal Revenue Service
Use this form if you want to request approval to have an agent file returns and make
deposits or payments of employment or other withholding taxes or if you want to
revoke an existing appointment.
For IRS use:
• If you are an employer or payer who wants to request approval, complete Parts 1
and 2 and sign Part 2. Then give it to the agent. Have the agent complete Part 3 and
sign it.
• If you are an employer or payer who wants to request approval, complete Parts 1
and 2 and sign Part 2. Then give it to the agent. Have the agent complete Part 3 and
sign it.
Note. This appointment is not effective until we approve your request. See the
instructions for filing Form 2678 on page 3.
Note. This appointment is not effective until we approve your request. See the
instructions for filing Form 2678 on page 3.
• If you are an employer, payer, or agent who wants to revoke an existing appointment,
complete all three parts. In this case, only one signature is required.
• If you are an employer, payer, or agent who wants to revoke an existing appointment,
complete all three parts. In this case, only one signature is required.
Part 1: Why you are filing this form...
(Check one)
✔
You want to appoint an agent for tax reporting, depositing, and paying.
You want to revoke an existing appointment.
Part 1: Why you are filing this form...
(Check one)
✔
You want to appoint an agent for tax reporting, depositing, and paying.
You want to revoke an existing appointment.
For IRS use:
Part 2: Employer or Payer Information: Complete this part if you want to appoint an agent or revoke an appointment.
Part 2: Employer or Payer Information: Complete this part if you want to appoint an agent or revoke an appointment.
1 Employer identification number (EIN)
1 Employer identification number (EIN)
—
2 Employer’s or payer’s name
(not your trade name)
2 Employer’s or payer’s name
(not your trade name)
3 Trade name (if any)
3 Trade name (if any)
4 Address
—
4 Address
Number
Street
Suite or room number
City
ZIP code
State
5 Forms for which you want to appoint an agent or revoke the agent’s appointment to file.
(Check all that apply.)
For ALL
employees/
payees
For SOME
employees/
payees
✔
Form 940, 940-PR (Employer's Annual Federal Unemployment (FUTA) Tax Return)*
Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return)
Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural Employees)
Form 944, 944-PR, 944-SS, 944(SP) (Employer’s ANNUAL Federal Tax Return)
Form 945 (Annual Return of Withheld Federal Income Tax)
Form CT-1 (Employer’s Annual Railroad Retirement Tax Return)
Form CT-2 (Employee Representative's Quarterly Railroad Tax Return)
Number
Street
Suite or room number
City
5 Forms for which you want to appoint an agent or revoke the agent’s appointment to file.
(Check all that apply.)
For ALL
employees/
payees
For SOME
employees/
payees
✔
Form 940, 940-PR (Employer's Annual Federal Unemployment (FUTA) Tax Return)*
Form 941, 941-PR, 941-SS (Employer’s QUARTERLY Federal Tax Return)
Form 943, 943-PR (Employer’s Annual Federal Tax Return for Agricultural Employees)
Form 944, 944-PR, 944-SS, 944(SP) (Employer’s ANNUAL Federal Tax Return)
Form 945 (Annual Return of Withheld Federal Income Tax)
Form CT-1 (Employer’s Annual Railroad Retirement Tax Return)
Form CT-2 (Employee Representative's Quarterly Railroad Tax Return)
✔
ZIP code
State
✔
*Generally you cannot appoint an agent to report, deposit, and pay taxes reported on Form 940, Employer's Annual Federal
Unemployment (FUTA) Tax Return, unless you are a home care service recipient.
Check here if you are a home care service recipient, and you want to appoint the agent to report, deposit, and pay FUTA
taxes for you. See the instructions.
*Generally you cannot appoint an agent to report, deposit, and pay taxes reported on Form 940, Employer's Annual Federal
Unemployment (FUTA) Tax Return, unless you are a home care service recipient.
Check here if you are a home care service recipient, and you want to appoint the agent to report, deposit, and pay FUTA
taxes for you. See the instructions.
I am authorizing the IRS to disclose otherwise confidential tax information to the agent relating to the authority granted under
this appointment, including disclosures required to process Form 2678. The agent may contract with a third party, such as a
reporting agent or certified public accountant, to prepare or file the returns covered by this appointment, or to make any
required deposits and payments. Such contract may authorize the IRS to disclose confidential tax information of the
employer/payer and agent to such third party. If a third party fails to file the returns or make the deposits and payments, the
agent and employer/payer remain liable.
I am authorizing the IRS to disclose otherwise confidential tax information to the agent relating to the authority granted under
this appointment, including disclosures required to process Form 2678. The agent may contract with a third party, such as a
reporting agent or certified public accountant, to prepare or file the returns covered by this appointment, or to make any
required deposits and payments. Such contract may authorize the IRS to disclose confidential tax information of the
employer/payer and agent to such third party. If a third party fails to file the returns or make the deposits and payments, the
agent and employer/payer remain liable.
Print your name here
Sign your
name here
Date
Print your title here
/
/
HHCSR
Best daytime phone
Print your name here
Sign your
name here
Date
Print your title here
/
/
Now give this form to the agent to complete. ■a
For Paperwork Reduction Act Notice, see the instructions.
Cat. No. 18770D
Form 2678 (Rev. 6-2011)
HHCSR
Best daytime phone
Now give this form to the agent to complete. ■a
For Paperwork Reduction Act Notice, see the instructions.
Cat. No. 18770D
Form 2678 (Rev. 6-2011)
Page 2
Form 2678 (Rev. 6-2011)
Page 2
Form 2678 (Rev. 6-2011)
Part 3: Agent Information: If you will be an agent for an employer or payer, or want to revoke an appointment, complete this part.
Part 3: Agent Information: If you will be an agent for an employer or payer, or want to revoke an appointment, complete this part.
6
Agent’s employer identification number (EIN)
6
Agent’s employer identification number (EIN)
7
Agent’s name (not trade name)
Seren Derin
7
Agent’s name (not trade name)
Seren Derin
8
Trade name (if any)
Stavros Ctr for Ind Liv Inc.
8
Trade name (if any)
Stavros Ctr for Ind Liv Inc.
9
Address
9
Address
0
4
—
3
7
6
5
5
4
1
210 Old Farm Road
Number
Street
Amherst
City
State
Date
/
/
Print your name here
Seren Derin
Print your title here
Fiscal Director
Best daytime phone
Form 2678 (Rev. 6-2011)
3
7
6
5
Street
5
4
1
Suite or room number
MA
City
State
01002
ZIP code
Check here if the employer is a home care service recipient receiving home care services through a program administered by a
federal, state, or local government agency.
Under penalties of perjury, I declare that I have examined this form and any attachments, and to the best of my knowledge and belief, it
is true, correct, and complete.
413-256-6692
—
Amherst
ZIP code
Under penalties of perjury, I declare that I have examined this form and any attachments, and to the best of my knowledge and belief, it
is true, correct, and complete.
Sign your
name here
Number
01002
Check here if the employer is a home care service recipient receiving home care services through a program administered by a
federal, state, or local government agency.
4
210 Old Farm Road
Suite or room number
MA
0
Sign your
name here
Date
/
/
Print your name here
Seren Derin
Print your title here
Fiscal Director
Best daytime phone
413-256-6692
Form 2678 (Rev. 6-2011)
Form 2678 (Rev. 6-2011)
Instructions for Form 2678
Section references are to the Internal Revenue Code.
Use this form if you want to request approval to have an agent
file returns and make deposits or payments of employment or
other withholding taxes or if you want to revoke an existing
appointment. You cannot use a prior version of this form. All
prior versions are obsolete and will not be accepted.
• If you want to appoint an agent, check the box in Part 1 that
says, “You want to appoint an agent for tax reporting,
depositing, and paying,” and complete Part 2.
Note. Generally you cannot appoint an agent to file an
aggregate Form 940. Beginning with the 2010 tax year, if you
are a home care service recipient you may request approval for
an agent to report, file, and pay taxes on a Form 940, by
checking the box in the footnote on line 5.
At the time this form went to print, proposed regulations
REG-137036-08 were issued to modify Regulations section
31.3504-1 to allow home care service recipients to appoint an
agent to report, file, and pay taxes on Form 940.
• If you are an agent and you want to accept an appointment,
complete Part 3. If you are a corporate officer, partner, or tax
matters partner, you must have the authority to execute this
appointment of agent.
Note. If the employer/payer will be making payments not
covered by the appointment, the employer/payer must file all
related returns and deposit and pay taxes for those payments.
When completing line 5, check the box(es) “For SOME
employees/payees.”
• If you are an employer, payer, or agent and you want to
revoke an existing appointment of an agent, check the box in
Part 1 that says, “You want to revoke an existing
appointment,” and complete Parts 2 and 3. However, only one
signature is required. If an existing appointment is revoked, the
IRS cannot disclose confidential tax information to anyone other
than the employer/payer for periods after the appointment is
revoked.
Filing Form 2678
Send Form 2678 to the address for your location in the Where
To File Chart later. We will send a letter to the agent after we
have approved the request. Until we approve the request, the
agent is not liable for filing any tax returns or making any
deposits or payments.
Filing Schedule R (Form 940) and Schedule R (Form 941)
An agent for a home care service recipient that files an
aggregate Form 940 must complete Schedule R (Form 940),
Allocation Schedule for Aggregate Form 940 Filers, and file it
with the aggregate Form 940.
An agent that files an aggregate Form 941 must complete
Schedule R (Form 941), Allocation Schedule for Aggregate Form
941 Filers, and file it with the aggregate Form 941.
Page
3
Form 2678 (Rev. 6-2011)
What are the reporting, deposit, and payment
requirements after the IRS approves the
appointment?
Instructions for Form 2678
Agents must follow the procedures in Revenue Procedure 70-6
for employment taxes (unless you are a subagent for a state
agent under Notice 2003-70) and Revenue Procedure 84-33 for
backup withholding. Agents for employers who are home care
service recipients receiving home care services through a
program administered by a federal, state, or local government
agency may also use this form. These agents are often referred
to as “fiscal/employer agents” and “household employer
agents.” All agents, employers, and payers remain liable for
filing all returns and making all tax deposits and payments while
this appointment is in effect. If an agent contracts with a third
party, such as a reporting agent or certified public accountant,
to prepare or file the returns covered by this appointment or to
make any required tax deposits or payments and the third party
fails to do so, the agent, employer, and payer remain liable.
Use this form if you want to request approval to have an agent
file returns and make deposits or payments of employment or
other withholding taxes or if you want to revoke an existing
appointment. You cannot use a prior version of this form. All
prior versions are obsolete and will not be accepted.
Privacy Act and Paperwork Reduction Act Notice. We ask
for the information on Form 2678 to carry out the Internal
Revenue laws of the United States. The principal purpose of this
information is to permit you to appoint an agent to act on your
behalf. You do not have to appoint an agent; however, if you
choose to appoint an agent, you must provide the information
requested on Form 2678. Our authority to collect this
information is section 3504. Section 6109 requires you and the
agent to provide your identification numbers. Failure to provide
this information could delay or prevent processing your
appointment of agent. Intentionally providing false information
could subject you and the agent to penalties.
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. However, section 6103 allows or
requires the IRS to disclose or give the information shown on
this form to others as described in the Code. For example, we
may disclose your tax information to the Department of Justice
for civil and criminal litigation, and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in
administering their tax laws. We may also disclose this
information to other countries under a tax treaty, to federal and
state agencies to enforce federal nontax criminal laws, or to
federal law enforcement and intelligence agencies to combat
terrorism.
The time needed to complete and file Form 2678 will vary
depending on individual circumstances. The estimated average
time is 2 hrs., 12 minutes. If you have comments concerning the
accuracy of this time estimate or suggestions for making Form
2678 simpler, we would be happy to hear from you. You can
send comments by email to *taxforms@irs.gov. Enter “Form
2678” on the subject line. Or write to: 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 Form 2678 to this address. Instead, see the Where
To File Chart later.
Section references are to the Internal Revenue Code.
• If you want to appoint an agent, check the box in Part 1 that
says, “You want to appoint an agent for tax reporting,
depositing, and paying,” and complete Part 2.
Note. Generally you cannot appoint an agent to file an
aggregate Form 940. Beginning with the 2010 tax year, if you
are a home care service recipient you may request approval for
an agent to report, file, and pay taxes on a Form 940, by
checking the box in the footnote on line 5.
At the time this form went to print, proposed regulations
REG-137036-08 were issued to modify Regulations section
31.3504-1 to allow home care service recipients to appoint an
agent to report, file, and pay taxes on Form 940.
• If you are an agent and you want to accept an appointment,
complete Part 3. If you are a corporate officer, partner, or tax
matters partner, you must have the authority to execute this
appointment of agent.
Note. If the employer/payer will be making payments not
covered by the appointment, the employer/payer must file all
related returns and deposit and pay taxes for those payments.
When completing line 5, check the box(es) “For SOME
employees/payees.”
• If you are an employer, payer, or agent and you want to
revoke an existing appointment of an agent, check the box in
Part 1 that says, “You want to revoke an existing
appointment,” and complete Parts 2 and 3. However, only one
signature is required. If an existing appointment is revoked, the
IRS cannot disclose confidential tax information to anyone other
than the employer/payer for periods after the appointment is
revoked.
Filing Form 2678
Send Form 2678 to the address for your location in the Where
To File Chart later. We will send a letter to the agent after we
have approved the request. Until we approve the request, the
agent is not liable for filing any tax returns or making any
deposits or payments.
Filing Schedule R (Form 940) and Schedule R (Form 941)
An agent for a home care service recipient that files an
aggregate Form 940 must complete Schedule R (Form 940),
Allocation Schedule for Aggregate Form 940 Filers, and file it
with the aggregate Form 940.
An agent that files an aggregate Form 941 must complete
Schedule R (Form 941), Allocation Schedule for Aggregate Form
941 Filers, and file it with the aggregate Form 941.
Page
3
What are the reporting, deposit, and payment
requirements after the IRS approves the
appointment?
Agents must follow the procedures in Revenue Procedure 70-6
for employment taxes (unless you are a subagent for a state
agent under Notice 2003-70) and Revenue Procedure 84-33 for
backup withholding. Agents for employers who are home care
service recipients receiving home care services through a
program administered by a federal, state, or local government
agency may also use this form. These agents are often referred
to as “fiscal/employer agents” and “household employer
agents.” All agents, employers, and payers remain liable for
filing all returns and making all tax deposits and payments while
this appointment is in effect. If an agent contracts with a third
party, such as a reporting agent or certified public accountant,
to prepare or file the returns covered by this appointment or to
make any required tax deposits or payments and the third party
fails to do so, the agent, employer, and payer remain liable.
Privacy Act and Paperwork Reduction Act Notice. We ask
for the information on Form 2678 to carry out the Internal
Revenue laws of the United States. The principal purpose of this
information is to permit you to appoint an agent to act on your
behalf. You do not have to appoint an agent; however, if you
choose to appoint an agent, you must provide the information
requested on Form 2678. Our authority to collect this
information is section 3504. Section 6109 requires you and the
agent to provide your identification numbers. Failure to provide
this information could delay or prevent processing your
appointment of agent. Intentionally providing false information
could subject you and the agent to penalties.
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. However, section 6103 allows or
requires the IRS to disclose or give the information shown on
this form to others as described in the Code. For example, we
may disclose your tax information to the Department of Justice
for civil and criminal litigation, and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in
administering their tax laws. We may also disclose this
information to other countries under a tax treaty, to federal and
state agencies to enforce federal nontax criminal laws, or to
federal law enforcement and intelligence agencies to combat
terrorism.
The time needed to complete and file Form 2678 will vary
depending on individual circumstances. The estimated average
time is 2 hrs., 12 minutes. If you have comments concerning the
accuracy of this time estimate or suggestions for making Form
2678 simpler, we would be happy to hear from you. You can
send comments by email to *taxforms@irs.gov. Enter “Form
2678” on the subject line. Or write to: 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 Form 2678 to this address. Instead, see the Where
To File Chart later.
Form 2678 (Rev. 6-2011)
Page
Where To File Chart
4
Form 2678 (Rev. 6-2011)
Page
Then use this
address ...
Department of the Treasury,
Internal Revenue Service,
Cincinnati, OH
45999
Where To File Chart
If you are in ...
Connecticut
Delaware
District of
Columbia
Illinois
Indiana
Kentucky
Maine
Maryland
Massachusetts
Michigan
New Hampshire
New Jersey
New York
North Carolina
Ohio
Pennsylvania
Rhode Island
South Carolina
Vermont
Virginia
West Virginia
Wisconsin
Department of the Treasury,
Internal Revenue Service,
Ogden, UT
84201
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Florida
Georgia
Hawaii
Idaho
Iowa
Kansas
Louisiana
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
North Dakota
Oklahoma
Oregon
South Dakota
Tennessee
Texas
Utah
Washington
Wyoming
No legal residence or place of
business in any state
Department of the Treasury,
Internal Revenue Service,
Ogden, UT
84201
No legal residence or place of
business in any state
Department of the Treasury,
Internal Revenue Service,
Ogden, UT
84201
Exempt organization or government
entity
Department of the Treasury,
Internal Revenue Service,
Ogden, UT 84201-0046
Exempt organization or government
entity
Department of the Treasury,
Internal Revenue Service,
Ogden, UT 84201-0046
If you are in ...
Connecticut
Delaware
District of
Columbia
Illinois
Indiana
Kentucky
Maine
Maryland
Massachusetts
Michigan
New Hampshire
New Jersey
New York
North Carolina
Ohio
Pennsylvania
Rhode Island
South Carolina
Vermont
Virginia
West Virginia
Wisconsin
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Florida
Georgia
Hawaii
Idaho
Iowa
Kansas
Louisiana
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
North Dakota
Oklahoma
Oregon
South Dakota
Tennessee
Texas
Utah
Washington
Wyoming
Then use this
address ...
Department of the Treasury,
Internal Revenue Service,
Cincinnati, OH
45999
Department of the Treasury,
Internal Revenue Service,
Ogden, UT
84201
4
Rev. 12/00
Form M-2848
Power of Attorney and
Declaration of Representative
Rev. 12/00
Form M-2848
Power of Attorney and
Declaration of Representative
Massachusetts
Department of
Revenue
See separate instructions. Please print or type.
Massachusetts
Department of
Revenue
See separate instructions. Please print or type.
Part 1 . Power of Attorney
Part 1 . Power of Attorney
A Name of taxpayer(s)
A Name of taxpayer(s)
Social Security number(s)
Social Security number(s)
Number and street, including apartment number or rural route
Federal Identification number
Number and street, including apartment number or rural route
Federal Identification number
City/Town
State
City/Town
State
Zip
B Hereby appoint(s) the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before any office of the Massachusetts Department of
Revenue for the following tax rnatter(s) (specify the type(s) of tax and year(s) or period(s) (date of death if estate tax))·
Name
SEREN DERIN
Type of tax (individual , corporate, etc.)
B Hereby appoint(s) the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before any office of the Massachusetts Department of
Revenue for the following tax rnatter(s) (specify the type(s) of tax and year(s) or period(s) (date of death if estate tax))·
Telephone number
Address
STAVROS C. I. L.
P.O. BOX 2130, AMHERST MA 01004
(413)256-6692
Name
ALL
Telephone number
Address
STAVROS C. I. L.
P.O. BOX 2130, AMHERST MA 01004
SEREN DERIN
Year(s) or period(s) (date ol death if estate tax)
INCOME TAX WITHHOLDING, TA-l
Zip
Type of tax (individual , corporate, etc.)
(413)256-6692
Year(s) or period(s) (date ol death if estate tax)
INCOME TAX WITHHOLDING, TA-l
ALL
C The attorney(s)-in-fact (or any of them) are authorized, subject to any limitations set forth below or to revocation, to receive confidential information and to
C The attorney(s)-in-fact (or any of them) are authorized, subject to any limitations set forth below or to revocation, to receive confidential information and to
perform any and all acts that the principal(s) can perform with respect to the above specified tax matters, such as the authority to sign any agreements,
consents or other documents.The authority does not include the power to substitute another representative (unless specifically added below) or the power
to receive refund checks.
perform any and all acts that the principal(s) can perform with respect to the above specified tax matters, such as the authority to sign any agreements,
consents or other documents.The authority does not include the power to substitute another representative (unless specifically added below) or the power
to receive refund checks.
List any specific additions or deletions to the acts otherwise authorized in this power of attorney:
List any specific additions or deletions to the acts otherwise authorized in this power of attorney:
D Originals of notices and other written communications go to the taxpayer(s). Send copies of all notices and all other written communications addressed
to the taxpayer(s) in proceedings involving the above tax matters to:
to the taxpayer(s) in proceedings involving the above tax matters to:
1 []! the appointee first named above, or
2
0
D Originals of notices and other written communications go to the taxpayer(s). Send copies of all notices and all other written communications addressed
1 []! the appointee first named above, or
2
(name of another appointee designated above)
0
(name of another appointee designated above)
This power of attorney revokes all earlier powers of attorney on file with the Department of Revenue for the same tax matters and years or periods covered by this power of attorney, except the following (specify to whom granted, date and address including Zip code or attach copies of earlier powers) :
This power of attorney revokes all earlier powers of attorney on file with the Department of Revenue for the same tax matters and years or periods covered by this power of attorney, except the following (specify to whom granted, date and address including Zip code or attach copies of earlier powers) :
E Signature of or for taxpayer(s). If signed by a corporate officer, partner, or fiduciary on behalf of the taxpayer, I certify that I have the authority to execute
this power of attorney on behalf of the taxpayer.
E Signature of or for taxpayer(s). If signed by a corporate officer, partner, or fiduciary on behalf of the taxpayer, I certify that I have the authority to execute
this power of attorney on behalf of the taxpayer.
Signature
Title (if applicable)
Date
Signature
EMPLOYER
Title (if applicable)
Date
EMPLOYER
If signing for a taxpayer who is not an individual, type or print your name
Signature
Title (if applicable)
If signing for a taxpayer who is not an individual, type or print your name
Date
Signature
Title (if applicable)
Date
- ----- --
- -
- --
- - - - - - - - - - - --
- --
- --
- - -- --
F If the power of attorney is granted to a person other than an attorney, certified public accountant, public accountant or enrolled agent, the taxpayer(s)
signature must be witnessed or notarized below.
The person(s) signing as or for the taxpayer(s) (check and complete one):
D
-
---,
- ----- --
- -
- --
- - - - - - - - - - - --
D
is/are known to and signed in the presence of the two disinterested witnesses whose signatures appear here:
Date
Signature of witness
Date
Signature of witness
Date
Signature of witness
Date
D
appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.
Signature of notary
appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.
Signature of notary
Date
Date
Part 2. Declaration of Representative.
All representatives must complete this section.
I declare that I am not currently under suspension or disbarment from practice within the Commonwealth or in any jurisdiction, that I am aware of regulations governing the practice of attorneys, certified public accountants, public accountants, enrolled agents and others, and that I am one of the following:
All representatives must complete this section.
I declare that I am not currently under suspension or disbarment from practice within the Commonwealth or in any jurisdiction, that I am aware of regulations governing the practice of attorneys, certified public accountants, public accountants, enrolled agents and others, and that I am one of the following:
1 a member in good standing of the bar of the highest court of the jurisdiction shown below;
1 a member in good standing of the bar of the highest court of the jurisdiction shown below;
2 duly qualified to practice as a certified public accountant or public accountant in the jurisdiction shown below;
2 duly qualified to practice as a certified public accountant or public accountant in the jurisdiction shown below;
3 enrolled as an agent under the requirements of Treasury Department Circular No. 230;
3 enrolled as an agent under the requirements of Treasury Department Circular No. 230;
4 a bona fide officer of the taxpayer organization;
4 a bona fide officer of the taxpayer organization;
5 a full-time employee of the taxpayer;
5 a full-time employee of the taxpayer;
6 a member of the taxpayer's immediate family (spouse, parent, child or sibling);
6 a member of the taxpayer's immediate family (spouse, parent, child or sibling);
7 a fiduciary for the taxpayer;
7 a fiduciary for the taxpayer;
8 other (attach statement)
8 other (attach statement)
and that I am authorized to represent the taxpayer identified in Part 1 for the tax matters specified there.
and that I am authorized to represent the taxpayer identified in Part 1 for the tax matters specified there.
Designation (insert appropriate
number from above list)
2.5M 6/01 CRP0101
Jurisdiction (state, etc.)
or enrollment card number
- - -- --
The person(s) signing as or for the taxpayer(s) (check and complete one):
is/are known to and signed in the presence of the two disinterested witnesses whose signatures appear here:
Part 2. Declaration of Representative.
- --
F If the power of attorney is granted to a person other than an attorney, certified public accountant, public accountant or enrolled agent, the taxpayer(s)
signature must be witnessed or notarized below.
Signature of witness
D
- --
Signature
1
Date
G) printed on recycled paper
Designation (insert appropriate
number from above list)
2.5M 6/01 CRP0101
Jurisdiction (state, etc.)
or enrollment card number
Signature
1
Date
G) printed on recycled paper
-
---,
-
'
··-- -- ---- - - - -
· -·· --
- -
- - -- - -
-
'
··-- -- ---- - - - -
Form M-2848 Instructions
General Information
To protect the confidentiality of tax records, Massachusetts law generally
prohibits the Department of Revenue from disclosing information contained
in tax returns or other documents filed with it to persons other than the taxpayer or the taxpayer's representative. For your protection, the Department
requires that you file a power of attorney before it will release tax information
to your representative. The power of attorney will also allow your representative to act on your behalf to the extent you indicate. Use Form M-2848,
Power of Attorney and Declaration of Representative, for this purpose if
you choose. You may file a power of attorney without using Form M-2848,
but it must contain the same information as Form M-2848 would.
You may use Form M-2848 to appoint one or more individuals to represent
you in tax matters before the Department of Revenue. You may use Form
M-2848 for any matters affecting any tax imposed by the Commonwealth,
and the power granted is limited to these tax matters.
Filing the Power of Attorney. You must file the original, a photocopy or
facsimile transmission (fax) of the power of attorney with each DOR office
in which your representative is to represent you. You do not have to file
another copy with other DOR officers or counsel who later have the matter
under consideration unless you are specifically asked to provide an additional copy.
Revoking a Power of Attorney. If you previously filed a power of attorney
and you want to revoke it, you may use Form M-2848 to change your representatives or alter the powers granted to them. File the form with the office of DOR in which you filed the earlier power. The new power of
attorney will revoke the earlier one for the same matters and tax periods
unless you specifically state otherwise.
If you want to revoke a power of attorney without executing a new one,
send a signed statement to each office of DOR in which you filed the earlier
power of attorney you are now revoking . List in this statement the name
and address of each representative whose authority is being revoked .
How to Complete Form M-2848
Part 1. Power of Attorney
A. Taxpayer's name, identification number and address. For individuals:
Enter your name, Social Security number and address in the space provided. If a joint return is involved, and you and your spouse are designating the same representative(s), also enter your spouse's name and Social
Security number, and your spouse's address (if different).
For a corporation, partnership or association: Enter the name, federal identification number and business address. If the power of attorney for a partnership will be used in a tax matter in which the name and Social Security
number of each partner have not previously been sent to DOR, list the
name and Social Security number of each partner in the available space
at the end of the form or on an attached sheet.
For a trust: Enter the name, title and address of the fiduciary, and the name
and federal identification number of the trust.
For an estate: Enter the name, title and address of the decedent's personal
representative , and the name and identification number of the estate. The
identification number for an estate is the decedent's Social Security number and includes the federal identification number if the estate has one.
B. Appointee. Enter the name(s), address(es) and telephone number(s)
of the individual(s) you appoint. Your representative must be an individual
and may not be an organization, firm or partnership.
Tax matters and years or periods. Consider each tax imposed by the
Commonwealth for each tax period as a separate tax matter. In the columns provided, clearly identify the type(s) of tax(es) and the year(s) or period(s) for which the power is granted. You may list any number of years or
periods and types of taxes on the same power of attorney. If the matter relates to estate tax, enter the date of the taxpayer's death instead of the
year or period.
If the power of attorney will be used in connection with a penalty that is not
related to a particular tax type, such as personal income or corporate , enter
the section of the General Laws which authorizes the penalty in the ''type
of tax" column.
C. Powers granted by Form M-2848. Your signature on Form M-2848
authorizes the individual(s) you designate (your representative or "attorneyin-facf') generally to perform any act you can perform. This includes executing waivers and offers of waivers of restrictions on assessment or collection
of deficiences in taxes, and waivers of notice of disallowance of a claim for
credit or refund . It also includes executing consents extending the legally allowed period for assessment or collection of taxes. The authority does not
include the power to substitute another representative (unless specifically
added to Form M-2848) or the power to receive refund checks.
If you do not want your representative to be able to perform any of these or
other specific acts, or if you want to give your representative the power to
delegate authority or substitute another representative , insert language excluding or adding these acts in the blank space provided.
D. Where you want copies to be sent. The Department of Revenue routinely sends originals of all notices to the taxpayer. You may also have
copies of all notices and all other written communications sent to your representative. Please check box 1 if you want copies of all notices or all communications sent to the first appointee named at the top of the form .
Check box 2 if you want copies sent to one of your other appointees. In this
case, list the name of the appointee.
E. Signature of taxpayer(s). For individuals: If a joint return is involved and
both husband and wife will be represented by the same individual(s), both
must sign the power of attorney unless one authorizes the other (in writing)
to sign for both. In that case, attach a copy of the authorization. However,
if the spouses are to be represented by different individuals, each may execute a power of attorney.
For a partnership: All partners must sign unless one partner is authorized
to act in the name of the partnership. A partner is authorized to act in the
name of the partnership if under state law the partner has authority to bind
the partnership.
For a corporation or association: An officer having authority to bind the entity must sign .
If you are signing the power of attorney for a taxpayer who is not an individual, such as a corporation or trust, please type or print your name on
the line below the signature line at the bottom of the form.
F. Notarizing or witnessing the power of attorney. A notary public or
two individuals with no stake in the tax matter must witness a power of attorney unless it is granted to an attorney, certified public accountant, public
accountant or enrolled agent.
Part 2. Declaration of Representative
Your representative must complete Part 2 to make a declaration containing
the following :
1. A statement that the representative is authorized to represent you as a
certified public accountant, public accountant, attorney, enrolled agent,
member of your immediate family, etc. If entering "eighf' in the "designation"
column, attach a statement indicating your relationship to the taxpayer.
2. The jurisdiction recognizing the representative , if applicable. For an attorney, certified public accountant or public accountant: Enter in the "jurisdiction" column the name of the state, possession, territory, commonwealth
or District of Columbia that has granted the declared professional recognition. For an enrolled agent: Enter the enrollment card number in the "jurisdiction" column.
3. The signature of the representative and the date signed.
· -·· --
- -
- - -- - -
Form M-2848 Instructions
General Information
To protect the confidentiality of tax records, Massachusetts law generally
prohibits the Department of Revenue from disclosing information contained
in tax returns or other documents filed with it to persons other than the taxpayer or the taxpayer's representative. For your protection, the Department
requires that you file a power of attorney before it will release tax information
to your representative. The power of attorney will also allow your representative to act on your behalf to the extent you indicate. Use Form M-2848,
Power of Attorney and Declaration of Representative, for this purpose if
you choose. You may file a power of attorney without using Form M-2848,
but it must contain the same information as Form M-2848 would.
You may use Form M-2848 to appoint one or more individuals to represent
you in tax matters before the Department of Revenue. You may use Form
M-2848 for any matters affecting any tax imposed by the Commonwealth,
and the power granted is limited to these tax matters.
Filing the Power of Attorney. You must file the original, a photocopy or
facsimile transmission (fax) of the power of attorney with each DOR office
in which your representative is to represent you. You do not have to file
another copy with other DOR officers or counsel who later have the matter
under consideration unless you are specifically asked to provide an additional copy.
Revoking a Power of Attorney. If you previously filed a power of attorney
and you want to revoke it, you may use Form M-2848 to change your representatives or alter the powers granted to them. File the form with the office of DOR in which you filed the earlier power. The new power of
attorney will revoke the earlier one for the same matters and tax periods
unless you specifically state otherwise.
If you want to revoke a power of attorney without executing a new one,
send a signed statement to each office of DOR in which you filed the earlier
power of attorney you are now revoking . List in this statement the name
and address of each representative whose authority is being revoked .
How to Complete Form M-2848
Part 1. Power of Attorney
A. Taxpayer's name, identification number and address. For individuals:
Enter your name, Social Security number and address in the space provided. If a joint return is involved, and you and your spouse are designating the same representative(s), also enter your spouse's name and Social
Security number, and your spouse's address (if different).
For a corporation, partnership or association: Enter the name, federal identification number and business address. If the power of attorney for a partnership will be used in a tax matter in which the name and Social Security
number of each partner have not previously been sent to DOR, list the
name and Social Security number of each partner in the available space
at the end of the form or on an attached sheet.
For a trust: Enter the name, title and address of the fiduciary, and the name
and federal identification number of the trust.
For an estate: Enter the name, title and address of the decedent's personal
representative , and the name and identification number of the estate. The
identification number for an estate is the decedent's Social Security number and includes the federal identification number if the estate has one.
B. Appointee. Enter the name(s), address(es) and telephone number(s)
of the individual(s) you appoint. Your representative must be an individual
and may not be an organization, firm or partnership.
Tax matters and years or periods. Consider each tax imposed by the
Commonwealth for each tax period as a separate tax matter. In the columns provided, clearly identify the type(s) of tax(es) and the year(s) or period(s) for which the power is granted. You may list any number of years or
periods and types of taxes on the same power of attorney. If the matter relates to estate tax, enter the date of the taxpayer's death instead of the
year or period.
If the power of attorney will be used in connection with a penalty that is not
related to a particular tax type, such as personal income or corporate , enter
the section of the General Laws which authorizes the penalty in the ''type
of tax" column.
C. Powers granted by Form M-2848. Your signature on Form M-2848
authorizes the individual(s) you designate (your representative or "attorneyin-facf') generally to perform any act you can perform. This includes executing waivers and offers of waivers of restrictions on assessment or collection
of deficiences in taxes, and waivers of notice of disallowance of a claim for
credit or refund . It also includes executing consents extending the legally allowed period for assessment or collection of taxes. The authority does not
include the power to substitute another representative (unless specifically
added to Form M-2848) or the power to receive refund checks.
If you do not want your representative to be able to perform any of these or
other specific acts, or if you want to give your representative the power to
delegate authority or substitute another representative , insert language excluding or adding these acts in the blank space provided.
D. Where you want copies to be sent. The Department of Revenue routinely sends originals of all notices to the taxpayer. You may also have
copies of all notices and all other written communications sent to your representative. Please check box 1 if you want copies of all notices or all communications sent to the first appointee named at the top of the form .
Check box 2 if you want copies sent to one of your other appointees. In this
case, list the name of the appointee.
E. Signature of taxpayer(s). For individuals: If a joint return is involved and
both husband and wife will be represented by the same individual(s), both
must sign the power of attorney unless one authorizes the other (in writing)
to sign for both. In that case, attach a copy of the authorization. However,
if the spouses are to be represented by different individuals, each may execute a power of attorney.
For a partnership: All partners must sign unless one partner is authorized
to act in the name of the partnership. A partner is authorized to act in the
name of the partnership if under state law the partner has authority to bind
the partnership.
For a corporation or association: An officer having authority to bind the entity must sign .
If you are signing the power of attorney for a taxpayer who is not an individual, such as a corporation or trust, please type or print your name on
the line below the signature line at the bottom of the form.
F. Notarizing or witnessing the power of attorney. A notary public or
two individuals with no stake in the tax matter must witness a power of attorney unless it is granted to an attorney, certified public accountant, public
accountant or enrolled agent.
Part 2. Declaration of Representative
Your representative must complete Part 2 to make a declaration containing
the following :
1. A statement that the representative is authorized to represent you as a
certified public accountant, public accountant, attorney, enrolled agent,
member of your immediate family, etc. If entering "eighf' in the "designation"
column, attach a statement indicating your relationship to the taxpayer.
2. The jurisdiction recognizing the representative , if applicable. For an attorney, certified public accountant or public accountant: Enter in the "jurisdiction" column the name of the state, possession, territory, commonwealth
or District of Columbia that has granted the declared professional recognition. For an enrolled agent: Enter the enrollment card number in the "jurisdiction" column.
3. The signature of the representative and the date signed.
FISCAL INTERMEDIARY PROGRAM
FISCAL INTERMEDIARY PROGRAM
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• ›’—’—ȱŠ—ȱ–Š’•’—ȱ™Š¢›˜••ȱ›Ž’œŽ›œǰȱŒ‘ŽŒ”œȱŠ—ȱ’›ŽŒȱŽ™˜œ’ȱœž‹œȱ˜ȱŒ˜—œž–Ž›œǯ
• ›˜ŒŽœœ’—ȱž˜–ŠŽȱ•ŽŠ›’—ȱ
˜žœŽȱ›Š—œŠŒ’˜—œȱ˜›ȱȂœȱŽ—›˜••Žȱ’—ȱ‘Žȱ’›ŽŒȱ
• ›’—’—ȱŠ—ȱ–Š’•’—ȱ™Š¢›˜••ȱ›Ž’œŽ›œǰȱŒ‘ŽŒ”œȱŠ—ȱ’›ŽŒȱŽ™˜œ’ȱœž‹œȱ˜ȱŒ˜—œž–Ž›œǯ
• ›˜ŒŽœœ’—ȱž˜–ŠŽȱ•ŽŠ›’—ȱ
˜žœŽȱ›Š—œŠŒ’˜—œȱ˜›ȱȂœȱŽ—›˜••Žȱ’—ȱ‘Žȱ’›ŽŒȱ
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deposit program.
’‘‘˜•’—ȱŠ—ȱŽ™˜œ’’—ȱ ’‘ȱ‘ŽȱȱŠ••ȱŠ™™›˜™›’ŠŽȱŽŽ›Š•ȱ’—Œ˜–ŽȱŠ¡ǰȱœ˜Œ’Š•ȱ
œŽŒž›’¢ȱŠ—ȱŽ’ŒŠ›ŽȱŠ¡Žœǯ
Ž™˜œ’’—ȱŠ••ȱŠ™™›˜™›’ŠŽȱŽ–™•˜¢Ž›ȱŠ¡Žœȱ ’‘ȱ‘Žȱȱ’—Œ•ž’—ȱŽ–™•˜¢Ž›ȱœ˜Œ’Š•ȱ
œŽŒž›’¢ȱŠ¡ŽœDzȱŽ’ŒŠ›ŽȱŠ¡ŽœȱŠ—ȱȱŠ¡Žœǯ
’‘‘˜•’—ȱŠ—ȱŽ™˜œ’’—ȱœŠŽȱ’—Œ˜–ŽȱŠ¡Žœǯ
Ž™˜œ’’—ȱŠ••ȱŠ™™›˜™›’ŠŽȱŽ–™•˜¢Ž›ȱŠ¡Žœȱ ’‘ȱ‘Žȱ˜––˜— ŽŠ•‘ȱ˜ȱŠœœŠŒ‘žœŽĴœȱ
’—Œ•ž’—ȱȱŠ—ȱŠŽȱ
ŽŠ•‘ȱ—œž›Š—ŒŽȱŠ¡Žœǯ
’•’—ȱŠ™™›˜™›’ŠŽȱ›Ž™˜›œȱ ’‘ȱ‘Žȱȱ’—Œ•ž’—ȱ˜›–ȱşŚŗǰȱ˜›–ȱşŚŖȱ˜›ȱ˜›–ȱşŚŖȱ
Š—ȱ˜›–œȱȬŘȱŠ—ȱȬřǯ
’•’—ȱŠ™™›˜™›’ŠŽȱ›Ž™˜›œȱ ’‘ȱ‘Žȱ˜––˜— ŽŠ•‘ȱ˜ȱŠœœŠŒ‘žœŽĴœȱ’—Œ•ž’—ȱ˜›–ȱŗǰȱ
˜›–ȱȬŗȱŠ—ȱ
ŽŠ•‘ȱ—œž›Š—ŒŽȱžŠ›Ž›•¢ȱ˜—›’‹ž’˜—ȱŽ™˜›ǯ
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deposit program.
’‘‘˜•’—ȱŠ—ȱŽ™˜œ’’—ȱ ’‘ȱ‘ŽȱȱŠ••ȱŠ™™›˜™›’ŠŽȱŽŽ›Š•ȱ’—Œ˜–ŽȱŠ¡ǰȱœ˜Œ’Š•ȱ
œŽŒž›’¢ȱŠ—ȱŽ’ŒŠ›ŽȱŠ¡Žœǯ
Ž™˜œ’’—ȱŠ••ȱŠ™™›˜™›’ŠŽȱŽ–™•˜¢Ž›ȱŠ¡Žœȱ ’‘ȱ‘Žȱȱ’—Œ•ž’—ȱŽ–™•˜¢Ž›ȱœ˜Œ’Š•ȱ
œŽŒž›’¢ȱŠ¡ŽœDzȱŽ’ŒŠ›ŽȱŠ¡ŽœȱŠ—ȱȱŠ¡Žœǯ
’‘‘˜•’—ȱŠ—ȱŽ™˜œ’’—ȱœŠŽȱ’—Œ˜–ŽȱŠ¡Žœǯ
Ž™˜œ’’—ȱŠ••ȱŠ™™›˜™›’ŠŽȱŽ–™•˜¢Ž›ȱŠ¡Žœȱ ’‘ȱ‘Žȱ˜––˜— ŽŠ•‘ȱ˜ȱŠœœŠŒ‘žœŽĴœȱ
’—Œ•ž’—ȱȱŠ—ȱŠŽȱ
ŽŠ•‘ȱ—œž›Š—ŒŽȱŠ¡Žœǯ
’•’—ȱŠ™™›˜™›’ŠŽȱ›Ž™˜›œȱ ’‘ȱ‘Žȱȱ’—Œ•ž’—ȱ˜›–ȱşŚŗǰȱ˜›–ȱşŚŖȱ˜›ȱ˜›–ȱşŚŖȱ
Š—ȱ˜›–œȱȬŘȱŠ—ȱȬřǯ
’•’—ȱŠ™™›˜™›’ŠŽȱ›Ž™˜›œȱ ’‘ȱ‘Žȱ˜––˜— ŽŠ•‘ȱ˜ȱŠœœŠŒ‘žœŽĴœȱ’—Œ•ž’—ȱ˜›–ȱŗǰȱ
˜›–ȱȬŗȱŠ—ȱ
ŽŠ•‘ȱ—œž›Š—ŒŽȱžŠ›Ž›•¢ȱ˜—›’‹ž’˜—ȱŽ™˜›ǯ
›’—Žȱ˜—œž–Ž›ȱŠ–Ž
›’—Žȱ˜—œž–Ž›ȱŠ–Ž
Date
Date
˜—œž–Ž›ȱ’—Šž›Ž
˜—œž–Ž›ȱ’—Šž›Ž
ȱ ŘŗŖȱ•ȱŠ›–ȱ˜Š
ȱ
ǯǯȱ˜¡ȱŘŗřŖȱ
ȱ –‘Ž›œǰȱȱŖŗŖŖŚ
ȱ ǻŞŖŖǼȱŚŚŘȬŗŗŞśȱȦȱ
ȱ ǻŚŗřǼȱŘśŜȬŜŜşŘȱȦ
ȱȱȱȱ ǯœŠŸ›˜œęǯ˜›
˜••ȱ›ŽŽȱŠ¡ȱǛDZȱŗȬŞŞŞȬŝŝřȬŚŘŞŗȱ
ŗŖȦŘŖȦŘŖŖś
ȱ ŘŗŖȱ•ȱŠ›–ȱ˜Š
ȱ
ǯǯȱ˜¡ȱŘŗřŖȱ
ȱ –‘Ž›œǰȱȱŖŗŖŖŚ
ȱ ǻŞŖŖǼȱŚŚŘȬŗŗŞśȱȦȱ
ȱ ǻŚŗřǼȱŘśŜȬŜŜşŘȱȦ
ȱȱȱȱ ǯœŠŸ›˜œęǯ˜›
˜••ȱ›ŽŽȱŠ¡ȱǛDZȱŗȬŞŞŞȬŝŝřȬŚŘŞŗȱ
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