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					Dear Homeowner:

Per your conversation with Belair-Edison Neighborhoods, Inc. (BENI) regarding your mortgage,
please complete the following intake packet in blue or black ink so that we can begin our
client/counselor relationship. This packet must be filled out, signed and returned to our office
before any counseling may begin.

BENI is a HUD-certified Housing Counseling Agency. Our office provides budget counseling and
loss mitigation services to assist clients in obtaining workout solutions with their lenders. Our
goal is to help you maintain homeownership whenever possible.

Many clients are calling to inquire about State and Federal programs. Please be aware that
these programs are designed for those who are behind on their mortgage. The ongoing ability
to pay your mortgage is critical to qualify for these programs. For more information regarding
these programs, please visit the following websites: www.mdhope.org, and
www.makinghomeaffordable.gov.

Please return the signed and completed intake packet as soon as possible. The packet may be
submitted any one of the following ways; via e-mail, facsimile, postal delivery or drop off.
Packets may be dropped off at our office Mon-Fri. between the hours of 1-4 p.m. Incomplete
packets will result in a delay of counseling services. Once your completed packet is received, it
will be assigned to a housing counselor. Please do not call the office for an update before you
are contacted by your counselor.

Congratulations in taking the first step to resolving your mortgage delinquency. We look
forward to working with you.

Sincerely,



Roy Miller                                          Lisa M. Carter
Housing Counselor                                   Housing Counselor
                                                Client Name: __________________________________


                                     DOCUMENT CHECKLIST:

PLEASE COMPLETE THIS INTAKE PACKET IN BLUE OR BLACK INK.

PLEASE SEND PHOTOCOPIES ONLY (ORIGINALS WILL NOT BE RETURNED).

□   BENI Intake Forms
□   Budget Worksheet
□   Proposed Action Plan
□   A “Hardship Letter,” which needs to include the following information:
         The reason you fell behind on your mortgage payments
         The date you fell behind
         How the situation has changed or will change since you fell behind (so that the mortgage
            company understands that you will be able to sustain a repayment or modified payment
            plan)
         Your desire to remain in your home
□   Copy of your state-issued photo identification
□   Copy of your most recent mortgage statement and/or payment coupon
□   Any materials that you have received from your mortgage company or an attorney
□   Two (2) months of bank statements for all accounts
□   Proof of income, which may include the following:
         Pay stubs for last 30 days
         Social Security awards letter
         Pension statement
         If self-employed, a year-to-date Profit and Loss Statement
□   Two (2) most recent years Federal and State Tax Returns, W-2’s, or 1099 (forms must be signed and
    dated)
□   Signed IRS Form 4506-T
□   Completed Dodd-Frank Certification
□   Payment for credit report made out to Belair-Edison Neighborhoods, Inc. in the amount of $10 for
    an individual or $18 for a joint report (Money Order ONLY).

PLEASE MAKE SURE YOU HAVE INCLUDED ALL OF THE REQUESTED DOCUMENTATION (LISTED
BELOW) BEFORE RETURNING THIS PACKET TO BELAIR-EDISON NEIGHBORHOODS, INC. (BENI).
                                                Client Name: __________________________________


                                   FURTHER DOCUMENTATION

Your lender may request additional information. Please have the following available upon request from
the lender:

   □   All closing documents from the most recent settlement, whether the purchase or most recent
       refinance of your home mortgage
   □   Other income documentation (including, but not limited to, child support, social security,
       renters income, government assistance)
   □   Most recent utility bill (electric, water)
   □   Most recent property tax bill
   □   Amount of cash on hand
   □   Student loan statement (if loan is deferred)



ADDITIONAL STEPS TO TAKE AS SOON AS YOU RECEIVE THIS PACKAGE:

   1. Contact your mortgage company. Call the toll-free number on the bottom of your last
      mortgage statement and ask to speak to a representative in the Loss Mitigation department.
      Ask the representative to send you a “workout packet” immediately.
   2. Start a communication log. (A blank communication log is included in this packet.) Keep track
      of every conversation that you have about your mortgage. This should include the date of the
      conversation, with whom you spoke, and the result of your conversation.
   3. Start saving! If you are granted a workout, the lender may require a down payment.
                                                    Client Name: __________________________________


Loan ID Number: _______________________

PLEASE ANSWER ALL OF THE QUESTIONS IN THIS PACKAGE.
Please check all appropriate answers. If a question does not apply, please use NA.

                     BORROWER                                            CO-BORROWER
BORROWER’S NAME:                                        BORROWER’S NAME:

SOCIAL SECURITY NUMBER:           DATE OF BIRTH:        SOCIAL SECURITY NUMBER:           DATE OF BIRTH:

HOME PHONE NUMBER WITH AREA CODE:                       HOME PHONE NUMBER WITH AREA CODE:

CELL OR WORK PHONE NUMBER WITH AREA CODE:               CELL OR WORK PHONE NUMBER WITH AREA CODE:

EMAIL ADDRESS:                                          EMAIL ADDRESS:

MAILING ADDRESS:                                        MAILING ADDRESS:

PROPERTY ADDRESS:                                       PROPERTY ADDRESS:

NAME OF EMPLOYER:                                       NAME OF EMPLOYER:

EMPLOYER ADDRESS:                                       EMPLOYER ADDRESS:

EMPLOYER PHONE:                                         EMPLOYER PHONE:

POSITION:                                               POSITION:

HOW LONG EMPLOYED/START DATE:                           HOW LONG EMPLOYED/START DATE:

CURRENT INCOME (GROSS ANNUAL AMOUNT):                   CURRENT INCOME* (GROSS ANNUAL AMOUNT):

*If no co-borrower, please include any additional household income, including non-borrower income.

Please choose one:         ___ American Indian/Alaskan Native       ___ Asian     ___ White

        ___ Black or African-American              ___ Native Hawaiian/Pacific Islander

Ethnicity:       ___ Hispanic              ___ Non-Hispanic

Family Size: ______________________ ____           Single Head of Household :     ___ Yes          ___ No

Disabled:        ___ Yes          ___ No
                                               Client Name: __________________________________


I want to:       ___ Keep the property        ___ Sell the property
The property is my:     ___ Primary residence         ___ Second home       ___ Investment
The property is:        ___ Owner-occupied            ___ Renter-occupied          ___ Vacant

Is the property listed for sale? ___ Yes        ___ No
Have you received an offer on the property?     ___ Yes        ___ No
If yes, provide the following information:
Date of offer: ___________________________             Amount of offer: $ _______________________
Agent’s Name: ___________________________              Agent’s Phone #: ________________________
For Sale by Owner?        ___ Yes        ___ No

Who pays the Real Estate Tax bill on your property?    ___ Lender  ___ I do
Are the taxes current? ___ Yes          ___ No
If no, when was the last time they were paid? _______________________________________________
Condominium or HOA fees?         ___ Yes        ___ No
If yes, name of condominium or HOA: __________________________ Phone #: __________________

Who pays the hazard insurance policy for your property?      ___ Lender      ___ I do
Name of Insurance Co.: ____________________________          Insurance Co. Phone: ______________

Have you filed for bankruptcy? ___ Yes         ___ No
If yes, has your bankruptcy been discharged?   ___ Yes    ___ No    Case Number: _____________

First Mortgage
Mortgage Company Name: ______________________________________________________________
When did mortgage start: _________ Current payment: __________ Current Interest Rate: _______
Loan number: ___________________ How many months are you behind: ______________________
What type of mortgage do you have?             Conventional        VA     FHA     ARM
        Balloon         Interest-Only Option Payment        Negative Amortization
If an ARM, when will rate reset? _______________________ FHA File Number: _________________

Second Mortgage (if applicable)
Mortgage Company Name: ______________________________________________________________
When did mortgage start: _________ Current payment: __________ Current Interest Rate: _______
Loan number: ___________________ How many months are you behind: ______________________
What type of mortgage do you have?             Conventional        VA     FHA     ARM
        Balloon         Interest-Only Option Payment        Negative Amortization
If an ARM, when will rate reset? _______________________ FHA File Number: _________________
                                              Client Name: __________________________________


                               HOUSEHOLD BUDGET WORKSHEET

Name(s) ______________________________________________________________________________

                  Totally Monthly Income                           Gross              Net
Source: _______________________________________________       $____________      $____________
Source: _______________________________________________       $____________      $____________
Source: _______________________________________________       $____________      $____________
Source: _______________________________________________       $____________      $____________

Total Monthly Income (Gross and Net)                          $____________      $____________

                    Housing Expenses                          Monthly Payments
                  1st Mortgage Payment                        $____________
                  2nd Mortgage Payment                        $____________
                       Utilities (BGE)                        $____________
          Condominium/HOA Fees/Ground Rent                    $____________
   Homeowners Insurance (If not part of mortgage payment)     $____________
                       Water/Sewer                            $____________

                   Total Housing Expenses                     $____________

                       Auto Expenses
                         Car Payment                          $____________
                              Gas                             $____________
                           Insurance                          $____________
                         Maintenance                          $____________
                    Tolls, EZ Pass, Parking                   $____________

                    Total Auto Expenses                       $____________

                       Consumer Debts
Creditor 1: ____________________________________________      $____________
Creditor 2: ____________________________________________      $____________
Creditor 3: ____________________________________________      $____________
Creditor 4: ____________________________________________      $____________
Creditor 5: ____________________________________________      $____________
Creditor 6: ____________________________________________      $____________

                    Total Consumer Debts                      $____________
                                               Client Name: __________________________________


                         HOUSEHOLD BUDGET WORKSHEET Continued

                        Discretionary                           Monthly Payments
                 Church Tithes and Offerings                    $____________
               Other Charitable Contributions                   $____________
                          Groceries                             $____________
                     Lunches, Meals Out                         $____________
                           Childcare                            $____________
                   School Tuition/Supplies                      $____________
                      School Activities                         $____________
                  Medical Bills and Co-Pays                     $____________
                   Prescription Medicines                       $____________
                 Pet Supplies and Vet Exams                     $____________
  Entertainment (alcohol, books, music, movies, sports, etc.)   $____________
             Newspaper, Magazine Subscriptions                  $____________
                       Cable, Internet                          $____________
                       Landline Phone                           $____________
                          Cell Phone                            $____________
                           Clothing                             $____________
             Personal Care Items (toiletries, etc.)             $____________
                     Hair Care, Nails, etc.                     $____________
                        Gifts, Holidays                         $____________
                 Memberships, Union Dues                        $____________
Other: _______________________________________________          $____________

                Total Discretionary Expenses                    $____________

                  Monthly Expense Totals
                    Housing Expenses                            $____________
                     Auto Expenses                              $____________
                    Consumer Debts                              $____________
                      Discretionary                             $____________

             Total Monthly Household Expenses                   $____________

                Monthly Surplus or Shortage
                     Total Net Income                           $____________
               Minus Total Monthly Expenses                     $____________
          Equals Monthly Surplus (+) or Shortage (-)            $____________
                                                Client Name: __________________________________


                                     PROPOSED ACTION PLAN

What action steps are you prepared to take in response to your current situation?

   □   Find an additional job                                  □   Investigate alternative daycare
   □   Have someone move in to help with                           providers
       expenses/rent a room                                    □   Pack meals instead of buying them
   □ Ask a family member to contribute                         □   Reduce utility expenses (turn off
   □ Modify transportation                                         lights, unplug appliances, conserve
            • Carpool                                              water)
            • Downsize car                                     □   Turn off/modify services
            • Combine trips/restrict                                    • Cable/internet
                driving                                                 • Landline telephone
   □ Sell your property                                                 • Satellite radio
   □ Ask your place of worship for                                      • Gym membership
       assistance
Other action steps?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________                  ________________________________
Client Signature                                               Date

_____________________________________________                  ________________________________
Client Signature                                               Date

Counselor recommendations:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________                  ________________________________
Counselor Signature                                            Date
                                                 Client Name: __________________________________


                            Counselor/Post-Purchase Client Agreement

Belair-Edison Neighborhoods, Inc. and its counselors agree to provide the following services:

    •   Development of a spending plan
    •   Analysis of mortgage default, including the amount and cause of default
    •   Presentation and explanation of reasonable options available to homeowner
    •   Assistance communicating with the mortgage servicer and other creditors
    •   Timely completion of promised action(s)
    •   Explanation of collection, loss mitigation, and foreclosure processes
    •   Identification of and referral to additional resources as needed
    •   Confidentiality, honesty, respect, and professionalism in all services

I/We, _______________________________________________________________________________,
agree to the following terms of service:

    •   I/We will always provide honest and complete information to the counselor, whether verbally or
        in writing.
    •   I/We will provide all necessary documentation, including follow-up information and close out
        documentation, within the requested timeframe.
    •   I/We will be on time for appointments and understand that if I/we are more than 15 minutes
        late without calling, our counselor can reschedule the appointment.
    •   I/We will call within 2 hours of a scheduled appointment if I/we are unable to attend.
    •   I/We will contact the counselor about any changes in our situation immediately
    •   I/We understand that breaking this agreement or failure to follow the agreed upon action plan
        may cause the counseling agency to terminate services.

_____________________________________________________                   __________________________
Homeowner                                                               Date

_____________________________________________________                   __________________________
Homeowner                                                               Date

_____________________________________________________                   __________________________
Counselor                                                               Date
                                                 Client Name: __________________________________

                        Homeownership Counseling Privacy Policy

Belair-Edison Neighborhoods, Inc. is committed to assuring the privacy of individuals and/or families
who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in
nature. We assure you that all information shared both orally and in writing will be managed within legal
and ethical considerations. Your “nonpublic personal information,” such as your total debt information,
income, living expenses and personal information concerning your financial circumstances, will be
provided to creditors, program monitors, and others only with your authorization and signature on our
agency’s authorization forms. We may also use anonymous aggregate case file information for the
purpose of evaluating our services, gathering valuable research information and designing future
programs.

Types of information that we gather about you
• Information we receive from you orally, on applications or other forms, such as your name, address,
   social security number, assets, and income;
• Information about your transactions with us, your creditors, or others, such as your account
   balance, payment history, parties to transactions and credit card usage; and
• Information we receive from a credit reporting agency, such as your credit history.

You may opt-out of certain disclosures
• You may have the opportunity to “opt-out” of disclosures of your nonpublic personal information to
   third parties (such as creditors), that is, direct us not to make those disclosures.
• If you choose to “opt-out”, we will not be able to answer questions from your creditors. If at any
   time, you wish to change your decision with regard to your “opt-out”, you may call us at 410-485-
   8422 and do so.

Release of your information to third parties
• So long as you have not opted-out, we may disclose some or all of the information that we collect,
    as described above, to your creditors or third parties where we have determined that it would be
    helpful to you, would aid us in counseling you, or is a requirement of grant awards which make our
    services possible.
• We may also disclose any nonpublic personal information about you or former customers to anyone
    as permitted by law (e.g. if we are compelled by legal process).
• Within the organization, we restrict access to nonpublic personal information about you to those
    employees who need to know that information to provide services to you. We maintain physical,
    electronic and procedural safeguards that comply with federal regulations to guard your nonpublic
    personal information.

___________________________________________________________                     ___________________
Signature                                                                       Date
                                                   Client Name: __________________________________


                        Credit Report Authorization and Privacy Disclosure Form

I hereby authorize and instruct Belair-Edison Neighborhoods, Inc. (hereinafter “BENI”) to obtain and
review my credit report. My credit report will be obtained from a credit reporting agency chosen by
BENI. I understand and agree that BENI intends to use the credit report for the purposes of evaluating
my financial readiness to purchase a home and/or to engage in post-purchase counseling activities.

My signature below also authorizes the release to credit reporting agencies of financial or other
information that I have supplied to BENI in connection with such evaluation. Authorization is further
granted to the credit reporting agency to use a copy of this form to obtain any information the credit
reporting agency deems necessary to complete my credit report.

In addition, in connection with determining my ability to obtain a loan, I

______ Authorize          ______ Do not authorize

BENI to share with potential mortgage lenders and/or counseling agencies my credit report and any
information I have provided, including any computations and assessments that have been produced
based upon such information. These lenders may contact me to discuss loans for which I may be eligible,
and these counseling agencies may contact me to discuss counseling services.

I understand that I may revoke my consent to these disclosures by notifying BENI in writing.

                                         _______                                                 ______
Client’s Name (Print)                                     Client’s Name (Print)

                                         _______                                                 ______
Client’s Signature                                        Client’s Signature

                                         _______                                                 ______
Social Security Number                                    Social Security Number

                                         _______                                                 ______
Date                                                      Date
                                               Client Name: __________________________________


                AUTHORIZATION TO RELEASE FILES AND INFORMATION

To: ___________________________________________             Loan #: __________________________
       Lender/Loan Servicer

Borrower's Name: _____________________________________________________________________
                 Print Name

Social Security #: ________________________________         Date of Birth: ____________________

Property Address: _____________________________________________________________________
                  Street

_______________________________________,             MD     ________________________________
City                                                        Zip Code

I, ___________________________________, hereby authorize you to discuss all aspects of my
mortgage account with my representatives named below and to provide my representatives with copies
of all the documents that they may request regarding my account. This Authorization is valid until
withdrawn in writing.

Roy Miller
Housing Counselor

Lisa M Carter
Housing Counselor

Counsel to Belair-Edison Neighborhoods, Inc.

Belair-Edison Neighborhoods, Inc.
3412 Belair Road
Baltimore, MD 21213



____________________________________________________                __________________________
Signature of Borrower                                               Date

____________________________________________________                __________________________
Signature of Borrower                                               Date
                                                 Client Name: __________________________________


             National Foreclosure Mitigation Counseling (NFMC) Agreement

1. I understand that Belair-Edison Neighborhoods, Inc. provides foreclosure mitigation counseling after
   which I will receive a written action plan consisting of recommendations for handling my finances,
   possibly including referrals to other housing agencies as appropriate.

2. I understand that Belair-Edison Neighborhoods, Inc. receives Congressional funds through the
   National Foreclosure Mitigation Counseling (NFMC) program and, as such, is required to share some
   of my personal information with NFMC program administrators or their agents for purposes of
   program monitoring, compliance and evaluation.

3. I give permission for NFMC program administrators and/or their agents to pull my credit report up
   to two additional times between ______________ and twelve (12) months from this day and to give
   authorization for NFMC program administrators and/or their agents to follow-up with me between
   this day and twelve (12) months from now for the purposes of program evaluation.

4. I acknowledge that I have received a copy of Belair-Edison Neighborhoods, Inc.’s Privacy Policy.

5. I may be referred to another agency or agencies as appropriate that may be able to assist with
   particular concerns that have been identified. I understand that I am not obligated to use any of the
   services offered to me.

6. A counselor may answer questions and provide information, but not give legal advice. If I want legal
   advice, I will be referred for appropriate assistance.

7. I understand that Belair-Edison Neighborhoods, Inc. provides information and education on
   numerous loan products and housing programs and I further understand that the housing
   counseling I receive from Belair-Edison Neighborhoods, Inc. in no way obligates me to choose any of
   these particular loan products or housing programs.


Client’s signature: _____________________________________               Date: _____________________

Client’s signature: _____________________________________               Date: _____________________
                                                Client Name: __________________________________


                                       HARDSHIP AFFIDAVIT
                        Use back of page for further explanation, if necessary.

I/We am/are requesting review under the Making Home Affordable or other loss mitigation program. I
am having difficulty making my monthly mortgage payment because of financial difficulties created by
(please check all that apply):

   □   My household income has been reduced as a result of ________________________________.
       (For example, unemployment, underemployment, reduced pay hours, decline in business
       earning, death, disability, or divorce of a borrower, co-borrower, or other contributing member
       of my household.)
   □   My expenses have increased because _______________________________________________.
       (For example, monthly mortgage payment reset, high medical or health care costs, uninsured
       losses, increased utilities or property taxes.)
   □   My monthly debt payments are excessive, and I am overextended with my creditors. (Debt
       includes credit cards, home equity, student loans, or other debt.)
   □   My cash reserves, including all liquid assets, are not enough to maintain my current mortgage
       payment and cover my basic living expenses at the same time.
   □   Other: ________________________________________________________________________
       ______________________________________________________________________________
       ______________________________________________________________________________
       ______________________________________________________________________________
       ______________________________________________________________________________
       ______________________________________________________________________________

   Explanation: _______________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
   __________________________________________________________________________________
                                                Client Name: __________________________________


                               MORTGAGE COMMUNICATION LOG

You can use this sheet to keep track of all communications about your mortgage and/or other financial
matters.

Date         Time       Name of person you spoke with,          What you talked about including
                        including contact information           decisions made, any action items, or
                                                                other information




                                    KEEP FOR YOUR RECORDS.
Form    4506-T                                       Request for Transcript of Tax Return
(Rev. January 2010)                                                                                                                          OMB No. 1545-1872

Department of the Treasury                           Request may be rejected if the form is incomplete or illegible.
Internal Revenue Service
Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can also call 1-800-829-1040 to
order a transcript. If you need a copy of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.
   1a Name shown on tax return. If a joint return, enter the name shown first.                         1b First social security number on tax return or
                                                                                                          employer identification number (see instructions)


   2a If a joint return, enter spouse’s name shown on tax return.                                      2b Second social security number if joint tax return



   3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code



   4 Previous address shown on the last return filed if different from line 3



   5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address,
     and telephone number. The IRS has no control over what the third party does with the tax information.




Caution. If the transcript is being mailed to a third party, ensure that you have filled in line 6 and line 9 before signing. Sign and date the form once you
have filled in these lines. Completing these steps helps to protect your privacy.

   6     Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form
         number per request.
    a    Return Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect
         changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series,
         Form 1065, Form 1120, Form 1120A, Form 1120H, Form 1120L, and Form 1120S. Return transcripts are available for the current year
         and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days . . . . . .

    b    Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty
         assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability
         and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 30 calendar days. .
    c    Record of Account, which is a combination of line item information and later adjustments to the account. Available for current year and
         3 prior tax years. Most requests will be processed within 30 calendar days . . . . . . . . . . . . . . . . . . .
   7     Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available
         after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days . .
   8     Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from
         these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this
         transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS.
         For example, W-2 information for 2007, filed in 2008, will not be available from the IRS until 2009. If you need W-2 information for retirement
         purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 45 days . . .
Caution. If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed
with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.

   9     Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four
         years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter
         each quarter or tax period separately.



Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax
information requested. If the request applies to a joint return, either husband or wife must sign. If signed by a corporate officer, partner, guardian, tax
matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute
Form 4506-T on behalf of the taxpayer. Note. For transcripts being sent to a third party, this form must be received within 120 days of signature date.
                                                                                                                     Telephone number of taxpayer on
                                                                                                                     line 1a or 2a


                Signature (see instructions)                                                    Date
Sign
Here             Title (if line 1a above is a corporation, partnership, estate, or trust)


                Spouse’s signature                                                              Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2.                                 Cat. No. 37667N                       Form   4506-T    (Rev. 1-2010)
Form 4506-T (Rev. 1-2010)                                                                                                                  Page   2

General Instructions                              Chart for all other transcripts                      Partnerships. Generally, Form 4506-T
                                                                                                    can be signed by any person who was a
Purpose of form. Use Form 4506-T to               If you lived in            Mail or fax to the     member of the partnership during any part
request tax return information. You can           or your business           “Internal Revenue      of the tax period requested on line 9.
also designate a third party to receive the       was in:                    Service” at:              All others. See Internal Revenue Code
information. See line 5.                                                                            section 6103(e) if the taxpayer has died, is
Tip. Use Form 4506, Request for Copy of           Alabama, Alaska,                                  insolvent, is a dissolved corporation, or if a
Tax Return, to request copies of tax              Arizona, Arkansas,         RAIVS Team             trustee, guardian, executor, receiver, or
returns.                                          California, Colorado,      P.O. Box 9941          administrator is acting for the taxpayer.
Where to file. Mail or fax Form 4506-T to         Florida, Hawaii, Idaho,    Mail Stop 6734         Documentation. For entities other than
the address below for the state you lived in,     Iowa, Kansas,              Ogden, UT 84409        individuals, you must attach the
                                                  Louisiana, Minnesota,
or the state your business was in, when                                                             authorization document. For example, this
                                                  Mississippi,
that return was filed. There are two address                                                        could be the letter from the principal officer
                                                  Missouri, Montana,
charts: one for individual transcripts (Form                                                        authorizing an employee of the corporation
                                                  Nebraska, Nevada,
1040 series and Form W-2) and one for all                                                           or the Letters Testamentary authorizing an
                                                  New Mexico,
other transcripts.                                North Dakota,                                     individual to act for an estate.
   If you are requesting more than one            Oklahoma, Oregon,
transcript or other product and the chart         South Dakota,                                     Privacy Act and Paperwork Reduction
below shows two different RAIVS teams,            Tennessee, Texas,                                 Act Notice. We ask for the information on
send your request to the team based on            Utah, Washington,                                 this form to establish your right to gain
the address of your most recent return.           Wyoming, a foreign                                access to the requested tax information
Automated transcript request. You can             country, or A.P.O. or                             under the Internal Revenue Code. We
call 1-800-829-1040 to order a transcript         F.P.O. address
                                                                             801-620-6922           need this information to properly identify
through the automated self-help system.                                                             the tax information and respond to your
Follow prompts for “questions about your          Connecticut,                                      request. You are not required to request
tax account” to order a tax return                Delaware, District of                             any transcript; if you do request a
transcript.                                       Columbia, Georgia,                                transcript, sections 6103 and 6109 and
                                                  Illinois, Indiana,         RAIVS Team             their regulations require you to provide this
Chart for individual                              Kentucky, Maine,           P.O. Box 145500        information, including your SSN or EIN. If
                                                                             Stop 2800 F            you do not provide this information, we
transcripts (Form 1040 series                     Maryland,
                                                                             Cincinnati, OH 45250   may not be able to process your request.
                                                  Massachusetts,
and Form W-2)                                     Michigan, New                                     Providing false or fraudulent information
                                                  Hampshire, New                                    may subject you to penalties.
If you filed an             Mail or fax to the    Jersey, New York,                                    Routine uses of this information include
individual return           “Internal Revenue     North Carolina,                                   giving it to the Department of Justice for
and lived in:               Service” at:          Ohio, Pennsylvania,                               civil and criminal litigation, and cities,
                                                  Rhode Island, South                               states, and the District of Columbia for use
Florida, Georgia,           RAIVS Team
                                                  Carolina, Vermont,                                in administering their tax laws. We may
North Carolina,             P.O. Box 47-421       Virginia, West Virginia,
South Carolina              Stop 91                                                                 also disclose this information to other
                                                  Wisconsin                  859-669-3592           countries under a tax treaty, to federal and
                            Doraville, GA 30362
                                                                                                    state agencies to enforce federal nontax
                            770-455-2335                                                            criminal laws, or to federal law enforcement
Alabama, Kentucky,                                Line 1b. Enter your employer identification       and intelligence agencies to combat
                            RAIVS Team            number (EIN) if your request relates to a
Louisiana,                                                                                          terrorism.
                            Stop 6716 AUSC        business return. Otherwise, enter the first
Mississippi,                                                                                           You are not required to provide the
                            Austin, TX 73301      social security number (SSN) shown on the
Tennessee, Texas, a                                                                                 information requested on a form that is
                                                  return. For example, if you are requesting
foreign country, or                                                                                 subject to the Paperwork Reduction Act
                                                  Form 1040 that includes Schedule C
A.P.O. or F.P.O.                                                                                    unless the form displays a valid OMB
                            512-460-2272          (Form 1040), enter your SSN.
address                                                                                             control number. Books or records relating
                                                  Line 6. Enter only one tax form number per        to a form or its instructions must be
Alaska, Arizona,            RAIVS Team            request.                                          retained as long as their contents may
California, Colorado,       Stop 37106            Signature and date. Form 4506-T must be           become material in the administration of
Hawaii, Idaho, Illinois,    Fresno, CA 93888      signed and dated by the taxpayer listed on        any Internal Revenue law. Generally, tax
Indiana, Iowa, Kansas,
                                                  line 1a or 2a. If you completed line 5            returns and return information are
Michigan, Minnesota,
                                                  requesting the information be sent to a           confidential, as required by section 6103.
Montana, Nebraska,
                                                  third party, the IRS must receive Form               The time needed to complete and file
Nevada, New Mexico,
North Dakota,
                                                  4506-T within 120 days of the date signed         Form 4506-T will vary depending on
Oklahoma, Oregon,
                                                  by the taxpayer or it will be rejected.           individual circumstances. The estimated
South Dakota, Utah,                                  Individuals. Transcripts of jointly filed      average time is: Learning about the law
Washington,                                       tax returns may be furnished to either            or the form, 10 min.; Preparing the form,
Wisconsin, Wyoming          559-456-5876          spouse. Only one signature is required.           12 min.; and Copying, assembling, and
                                                  Sign Form 4506-T exactly as your name             sending the form to the IRS, 20 min.
Arkansas,                   RAIVS Team            appeared on the original return. If you              If you have comments concerning the
Connecticut, Delaware,      Stop 6705 P-6         changed your name, also sign your current         accuracy of these time estimates or
District of Columbia,       Kansas City, MO       name.                                             suggestions for making Form 4506-T
Maine, Maryland,            64999                    Corporations. Generally, Form 4506-T           simpler, we would be happy to hear from
Massachusetts,                                    can be signed by: (1) an officer having legal     you. You can write to the Internal Revenue
Missouri, New                                     authority to bind the corporation, (2) any        Service, Tax Products Coordinating
Hampshire, New                                    person designated by the board of                 Committee, SE:W:CAR:MP:T:T:SP, 1111
Jersey, New York,                                 directors or other governing body, or (3)         Constitution Ave. NW, IR-6526,
Ohio, Pennsylvania,                               any officer or employee on written request        Washington, DC 20224. Do not send the
Rhode Island, Vermont,      816-292-6102          by any principal officer and attested to by       form to this address. Instead, see Where to
Virginia, West Virginia                           the secretary or other officer.                   file on this page.