Authorization for Release of Federal Tax Data
Authorization for Release of Federal Tax Data
This form will be used to validate federal tax return information that you provide to the Department of State. The information you supply will be compared to that shown on official Internal Revenue Service records. IRS data may include the return or a transcript of information contained on the return, as well as any other federal tax information concerning the years authorized. The name and mailing address of the Agency Office to where information is to be sent is:
| Director, National Visa Center United States |[pic] |
|Department of State ATTN: CMR |MNL2006123456 |
|32 Rochester Avenue | |
|Portsmouth, NH 03801-2909 | |
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To Be Completed by Sponsor
a) Sponsor Name: __________________________________ Social Security Number: ________________
b) Spouse's Name: __________________________________ Social Security Number: ________________
(if joint return filed)
c) Current Street Address: __________________________________________________________________
City: ______________________________________ State: _____ Zip Code: __________________
d) Tax Years included with Affidavit of Support: ___________ __________ __________
Your signature(s) indicates that you authorize the Internal Revenue Service to provide information with respect to your Form 1040 tax returns for the above years to the agency designated above. If a joint return was filed, either the husband or wife must sign.
Do not sign and date this release form until you are ready to mail it
with all the documents re quested by the National Visa Center
_______________________________________________________ _______________________
Signature of Sponsor Date
_______________________________________________________ _______________________
Signature of Spouse Date
Privacy Act Notice
We ask for the information on this form to establish our right to gain access to your tax form or transcript under the Internal Revenue Code including sections 6130 and 6109. We need to gain access to your tax information or transcript in order to verify the accuracy of the information you have provided. If you do not provide the authorization, we may not be able to process the VISA application. We may give the information to the Department of Justice or other appropriate law enforcement officials, as provided by law. The information gathered may also be used for internal IRS compliance purposes.
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Do not write in this space
Post MANILA
TY ____________________ TY ____________________ TY ____________________
____________________ ____________________ ____________________
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