Form 8821 (Revised April 2004) Tax Information Authorization

Summary: This is an example of Form 8821 (Revised April 2004) that provides permission from the taxpayer to the I.R.S. to discuss tax matters with appointed individuals as explained in the text. The completed line items are:

1. Taxpayer information.:
- Taxpayer name(s) and address (type or print) field contains
- - John Oak
  - 8821 Dogwood Lane
  - Anyplace, North Carolina 28000
- Social security number(s) field contains 000-00-0003
- Daytime telephone number field contains (910) 555-4321
2. Appointee.:
- Name and address (type or print) field contains
- - Jane Birch
  - 12 Peartree Lane
  - Anyplace, North Carolina 28000
- Telephone Number field contains (910) 555-3210
3. Tax Matters.:
- a. Type of tax (Income, Employment, Excise, etcetera) field contains Income
- b. Tax Form Number (1040, 941, 720, etcetera) field contains 1040
- c. Year(s) or Period(s) field contains 2000, 2001, 2002
5. Disclosure of tax information (you must check the box on line 5a or b unless the box on line 4 is checked):
- 5a. If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing basis, check this box checkbox checked
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 covered.
- Signature field contains John Oak
- Date field contains 2/20/04
- Print name field contains John Oak

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