Form 8821 Tax Information Authorization Information about Form 8821 and its instructions is at www.irs.gov/form8821. Do not sign this form unless all applicable lines have been completed. Do not use Form 8821 to request copies of your tax returns or to authorize someone to represent you. Name OMB No. 1545-1165 For IRS Use Only Received by: (Rev. March 2015) Department of the Treasury Internal Revenue Service Telephone Function Date 1 Taxpayer information. Taxpayer must sign and date this form on line 7. Taxpayer name and address Taxpayer identification number(s) Daytime telephone number Plan number (if applicable) 2 Appointee. If you wish to name more than one appointee, attach a list to this form. Check here if a list of additional appointees is attached CAF No. Name and address PTIN Telephone No. Fax No. Check if new: Address Telephone No. Fax No. 3 Tax Information. Appointee is authorized to inspect and/or receive confidential tax information for the type of tax, forms, periods, and specific matters you list below. See the line 3 instructions. (a) Type of Tax Information (Income, Employment, Payroll, Excise, Estate, Gift, Civil Penalty, Sec. 4980H Payments, etc.) (b) Tax Form Number (1040, 941, 720, etc.) (c) Year(s) or Period(s) (d) Specific Tax Matters 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. If you check this box, skip lines 5 and 6 . . . . . . 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 ................................. 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 . . . . . . . 6 Retention/revocation of prior tax information authorizations. If the line 4 box is checked, skip this line. If the line 4 box is not checked, the IRS will automatically revoke all prior Tax Information Authorizations on file unless you check the line 6 box and attach a copy of the Tax Information Authorization(s) that you want to retain. . . . . . . . . . . . . To revoke a prior tax information authorization(s) without submitting a new authorization, see the line 6 instructions. 7 Signature of taxpayer. 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 and tax periods shown on line 3 above. IF NOT COMPLETE, SIGNED, AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED. DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE. Signature Date Print Name Title (if applicable) Form 8821 (Rev. 3-2015) For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 11596P American LegalNet, Inc. www.FormsWorkFlow.com