941 form

Document Sample
941 form
Application for FEDTAX II Form 941 PIN Code





Agency Name: Agency EIN:



Agency Address:

City, State, ZIP:

(U.S. address required)



 Initial Application. Please issue a PIN Code to the person named below, who is

authorized to approve and transmit Form 941 tax returns for the above Employer

Identification Number (EIN). This authorization is effective when IRS has received your

PIN acknowledgment letter and will remain in effect until revoked.



 Notification of Change or Lost PIN. Please issue a PIN code to the person named

s s

below and revoke all previous PIN for this agency EIN. This change is effective for

Forms 941 beginning with the ________quarter of _______(year).



 Revocation. The person named below is no longer authorized to approve Form 941 for

this agency.

_____________________________________________________________________________



Agency approval: Signature______________________



Title______________________ Date____________

______________________________________________________________________________



I recognize my responsibility to ensure that all tax deposits and returns are transmitted

timely and accurately. By using this PIN Code, I certify, under penalty of perjury, that I have

s

examined and have the authority to sign the Form 941, Employer Quarterly Federal Tax

Return, that I am transmitting, including any accompanying schedules, and, to the best of my

knowledge and belief, is true, correct, and complete.



Signature of person to receive PIN ___________________________ Date ____________

Print Name ___________________________

Mailing Address ___________________________

(if different from above) ___________________________

____________________________

Phone number____________________________



Mail to: Internal Revenue Submission Processing Center or fax to: (859) 669-5418

201 West Rivercenter Blvd. Attn: Electronic Filing

Attn: efile Stop 2701

Covington, KY 41011


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