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Tax Information System

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					                                                   VIRGINIA DEPARTMENT OF TAXATION
                                              Integrated Revenue Management System (IRMS)
                                                       System Authorization Request

Completion of this form is voluntary, however, failure to complete the form as instructed will prevent us from granting access to TAX systems.
The use of the SSN is required in order to enforce accountability and compliance with the Commonwealth of Virginia Security Standard
SEC2001-01.1, and the Disclosure of Official Tax Information Handbook.

Organization Information: (Office Name and Address)
                                                                                                        Confidentiality of Tax Information
                                                                                                        All information available using Tax information systems
                                                                                                        is considered confidential. Confidential Tax information
                                                                                                        may be accessed and used only for the purpose for
AUTHORIZATION REQUESTED: (choose only one)          Effective Date:                                     which access and use is authorized by the Department
     Set-up Access for new IRMS User                                                                    of Taxation.     I understand that the unauthorized
     User Name:                                    Phone: (     )                                       disclosure of confidential Tax information is a Class 2
     User Title:                                   SSN:                                                 misdemeanor, and that I am bound by the provisions of
     E-mail address:                                                                                    Code of Virginia Section 58.1-3.
     Change in User Access– existing IRMS User ID:                                                      TAX System Access and Use
     User Name Change - New Name:                                                                        Never share your User ID or password with anyone
     Delete Access – existing IRMS User ID:                                                              Never let anyone use your access to IRMS
                                                                                                         Always log out of your system when not in use
Please check all that apply
FIPS Code:                                 Director of Finance            Treasurer
                                           Commissioner of Revenue                                        User Signature:
Agency Number:                             Setoff Agency               Collection Agency
   IRS User         DOA User          VEC User            EESMC Report Contact                            __________________________________________
   ABC User         DCSE User         Lottery User        EESMC File Transfer Only
    Other Entity (if not shown) :                                                                         Date: ____________________________________
                                                                                                          My signature above acknowledges my understanding
TYPE OF AUTHORITY NEEDED: Please check all that apply                                                     of the Confidentiality of Tax Information and TAX
                                                                                                          System Access and Use Statements above.
      Primary Setoff Debt Coordinator     Primary Security Administrator
      Alternate Setoff Debt Coordinator   Alternate Security Administrator


Approved by (print):          ______________________________

Signed:                       ______________________________                         Date: ______________                Phone: (       ) _____________

Must be approved by primary or alternate security administrator.
FAX this form to: (804) 367-3023                                                                                                     SA-IRMS-E Rev. 5/07

				
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posted:8/12/2011
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Description: Tax Information System document sample