This form contains 45 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Authorize access via Intermediate Service Provider (checkbox)
Authorize access via Intermediate Service Provider Checkbox
Check this box when you want to authorize access to your IRS records via an Intermediate Service Provider.
Designee 1 (Name and contact information)
List of additional designees attached Checkbox
Check this box if you are attaching a separate list that names more than two designees.
Designee name and mailing address Text
Enter the designee's full name and complete mailing address (street, city, state, and ZIP) as you want it to appear on correspondence.
Send copies of notices and communications Checkbox
Check this box if you want this designee to be sent copies of notices and communications regarding the taxpayer. Fill only if 'Designee name and mailing address' is filled.
Depends on: Designee name and mailing address
CAF number Number
Enter the designee's CAF (Centralized Authorization File) number assigned by the IRS. Fill only if 'Designee name and mailing address' is filled.
Depends on: Designee name and mailing address
PTIN Text
Enter the designee's Preparer Tax Identification Number (PTIN) issued by the IRS. Fill only if 'Designee name and mailing address' is filled.
Max length: 11 characters
Depends on: Designee name and mailing address
Designee telephone number Text
Enter the designee's daytime telephone number, including area code and any required country or extension information. Fill only if 'Designee name and mailing address' is filled.
Depends on: Designee name and mailing address
Designee fax number Text
Enter the designee's fax number, including area code if applicable. Fill only if 'Designee name and mailing address' is filled.
Depends on: Designee name and mailing address
New address Checkbox
Check this box if the address you entered for this designee is new or has changed. Fill only if 'Designee name and mailing address' is filled.
Depends on: Designee name and mailing address
New telephone number Checkbox
Check this box if the telephone number you entered for this designee is new or has changed. Fill only if 'Designee telephone number' is filled.
Depends on: Designee telephone number
New fax number Checkbox
Check this box if the fax number you entered for this designee is new or has changed. Fill only if 'Designee fax number' is filled.
Depends on: Designee fax number
Designee 2 (Name and contact information)
Designee 2 — Name and address Text
Enter Designee 2’s full name and mailing address (street, city, state, and ZIP), and company name if applicable.
Send copies of notices and communications Checkbox
Check this box if you want copies of notices and communications to be sent to this designee. Fill only if 'Designee 2 — Name and address' is filled.
Depends on: Designee 2 — Name and address
CAF number (Designee 2) Text
Enter the CAF (Centralized Authorization File) number assigned to Designee 2 if available. Fill only if 'Designee 2 — Name and address' is filled.
Depends on: Designee 2 — Name and address
PTIN (Designee 2) Text
Enter Designee 2’s Preparer Tax Identification Number (PTIN) if they have one. Fill only if 'Designee 2 — Name and address' is filled.
Max length: 11 characters
Depends on: Designee 2 — Name and address
Telephone number (Designee 2) Text
Enter Designee 2’s daytime telephone number including area code and any extension if applicable. Fill only if 'Designee 2 — Name and address' is filled.
Depends on: Designee 2 — Name and address
Fax number (Designee 2) Text
Enter Designee 2’s fax number including area code, or leave blank if none. Fill only if 'Designee 2 — Name and address' is filled.
Depends on: Designee 2 — Name and address
Check if new: Address Checkbox
Check this box if the address shown for this designee is new or has changed. Fill only if 'Designee 2 — Name and address' is filled.
Depends on: Designee 2 — Name and address
Check if new: Telephone No. Checkbox
Check this box if the telephone number shown for this designee is new or has changed. Fill only if 'Telephone number (Designee 2)' is filled.
Depends on: Telephone number (Designee 2)
Check if new: Fax No. Checkbox
Check this box if the fax number shown for this designee is new or has changed. Fill only if 'Fax number (Designee 2)' is filled.
Depends on: Fax number (Designee 2)
For IRS Use Only
Received by Text
Enter the identifier, initials, or code of the IRS staff member who received or accepted this form.
Name (IRS staff) Text
Enter the full name of the IRS employee who received or processed this form.
Telephone (IRS staff) Text
Enter a daytime telephone number where the IRS staff member can be reached about this form, including area code and any extension if applicable.
Function/Title Text
Enter the job title or role of the IRS staff member who handled this form (for example, Reviewer or Examiner).
Date received Date
Enter the date the IRS received or processed this form.
Retention/revocation of prior tax information authorizations
Retain prior tax information authorizations (line 5) Checkbox
Check this box if you want the IRS to retain prior tax information authorization(s) listed on the attached copy instead of revoking them (see line 5 instructions).
Specific use not recorded on the Centralized Authorization File (CAF)
Specific use not recorded on the Centralized Authorization File (CAF) Checkbox
Check this box if the tax information authorization is for a specific use that is not recorded on the CAF (if you check this box, follow the form instructions and skip line 5).
Tax information Row 1
Type of Tax Information Text
Enter the category of tax information you are authorizing access to (for example: Income, Employment, Payroll, Excise, Estate, Gift, Civil Penalty, Sec. 4980H payments, etc.).
Tax Form Number Number
Enter the IRS tax form number that corresponds to the tax information being requested.
Year(s) or Period(s) Number
Enter the tax year(s) or specific period(s) for which the authorization applies.
Specific Tax Matters Text
Provide any specific issues, account numbers, or detailed matters related to the tax information you want to authorize access to.
Tax information Row 2
Type of tax information Text
Enter the category of tax information being authorized (for example: Income, Employment, Payroll, Excise, Estate, Gift, Civil Penalty, Sec. 4980H payments, etc.).
Tax form number Text
Enter the tax form number associated with this information (for example: 1040, 941, 720, or other applicable form numbers).
Year(s) or period(s) Text
Enter the tax year(s) or specific reporting period(s) covered by this authorization (for example: 2020, 2018-2020, Q1 2021).
Specific tax matters Text
Describe the particular tax matters or issues authorized for access (for example: federal income tax liability, payroll tax details, or specific line items or issues).
Tax information Row 3
Type of tax information Text
Enter the category or nature of the tax information being authorized (for example, income, employment, payroll, excise, estate, gift, penalty, or specific payment types).
Tax form number Number
Provide the IRS tax form number that corresponds to the tax information being authorized.
Year(s) or period(s) Text
Specify the year or tax period(s) covered by this authorization (for example, a single year, a range of years, or specific date periods).
Specific tax matters Text
Describe any particular tax matters, issues, or line items to be included in this authorization (leave blank to authorize all matters for the listed forms and periods).
Taxpayer information
Taxpayer name and address Text
Enter the taxpayer’s full legal name followed by the mailing address (street address, city, state, and ZIP code).
Taxpayer identification number(s) Text
Enter the taxpayer identification number(s) assigned by the IRS (for example SSN or EIN) exactly as issued.
Daytime telephone number Text
Enter a daytime telephone number where the taxpayer can be reached, including area code and any necessary extension.
Plan number (if applicable) Text
If applicable, enter the plan number associated with the taxpayer’s retirement or benefit plan; otherwise leave this field blank.
Taxpayer signature and date
Taxpayer signature and print name Text
Enter the taxpayer's handwritten signature (or typed signature) and the taxpayer's printed full name to authorize the form.
Date signed Date
Enter the date on which the taxpayer signed this form.