Attachment 7-Tax Check Waiver Consent Form.pdf

PEACE CORPS: Tax Check Waiver

PRIOR TO COMPLETING THIS FORM, PLEASE BE SURE YOU HAVE REVIEWED THE TERMS OF THIS AGREEMENT.

By providing the information herein and by signing this waiver, I voluntarily authorize the Internal Revenue Service to release the tax return and return information indicated below. The return and return information will be used concerning my appointment or employment by the United States Government. This waiver is made pursuant to 26 U.S.C. 6103(c), which permits the release of return and return information, which would otherwise be confidential, to my designee.

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

Patricia Ulrich Chief, Information and Personnel Security

The information I am consenting to release is:

1. Have I failed to file a Federal income tax return for any of the last three (3) years for which filing of a return might have been required? If the filing date for the most recent required return has not yet lapsed on the date the IRS receives this waiver and IRS records do not indicate a return filing for the most recent required return, the “last three years” will mean the three years preceding the year for which returns are currently being filed and processed.

2. Were any of the returns in #1 filed more than forty-five (45) days after the due date for filing, determined with regard to any extension(s) of time for filing?

3. Have I failed to pay any tax, penalty, or interest liability during the current or last three calendar years within forty-five

(45) days of the date of which the IRS gave notice of the amount due and request for payment?

4. Am I now or have I ever been under investigation by the IRS for possible criminal offenses?

5. Has any civil penalty for fraud been assessed against me during the current or last three (3) calendar years?

If the information, which is to be released, includes a “Yes” answer to any of the above five questions, I authorize the Internal

Revenue Service to release any information pertaining to that question.

THE CANDIDATE MUST SIGN AND DATE THE BOTTOM OF THIS FORM.

MY NAME: ________________________________________________

MY SSN: ____ ____ ____ - ____ ____ - ____ ____ ____ ____

PHONE NUMBER(S): HOME: (______) ____________________ WORK: (______) ______________________

CURRENT ADDRESS: _______________________________________________________________________________

IF MARRIED AND FILED A JOINT RETURN:

SPOUSE NAME: _____________________________________________________

SPOUSE SSN: ____ ____ ____ - ____ ____ - ____ ____ ____ ____

NAMES AND ADDRESSES SHOWN ON RETURNS FOR THE LAST THREE (3) YEARS (IF DIFFERENT FROM ABOVE)

YEAR NAME ADDRESS

DATE: __________________________________________ _________________________________________________

WAIVER INVALID UNLESS THE DATE IS SIGNATURE OF THE TAXPAYER AUTHORIZING THE

HAND-WRITTEN BY TAXPAYER AND RECEIVED BY DISCLOSURE OF RETURN/RETURN INFORMATION

THE IRS WITHIN 120 DAYS OF THIS DATE