Form 872 (Rev. January 2001)

Form
(Rev. January 2001)
In reply refer to:
Department of the Treasury-Internal Revenue Service
872
Consent to Extend the Time to Assess Tax
Taxpayer Identification Number
(Name(s))
taxpayer(s) of
(Number, Street, City or Town, State, ZIP Code)
and the Commissioner of Internal Revenue consent and agree to the following:
(1) The amount of any Federal
tax due on any return(s) made by or
(Kind of tax)
for the above taxpayer(s) for the period(s) ended
may be assessed at any time on or before
. However, if
(Expiration date)
a notice of deficiency in tax for any such period(s) is sent to the taxpayer(s) on or before that date, then the time for
assessing the tax will be further extended by the number of days the assessment was previously prohibited, plus 60 days.
(2) The taxpayer(s) may file a claim for credit or refund and the Service may credit or refund the tax within 6 months after
this agreement ends.
MAKING THIS CONSENT WILL NOT DEPRIVE THE TAXPAYER(S) OF ANY APPEAL
RIGHTS TO WHICH THEY WOULD OTHERWISE BE ENTITLED.
YOUR SIGNATURE HERE
(Date signed)
SPOUSE'S SIGNATURE
(Date signed)
TAXPAYER'S REPRESENTATIVE
SIGN HERE
(Date signed)
CORPORATE
NAME
CORPORATE
OFFICER(S)
SIGN HERE
(Title)
(Date signed)
(Title)
(Date signed)
INTERNAL REVENUE SERVICE SIGNATURE AND TITLE
(Division Executive Name - see instructions)
(Division Executive Title - see instructions)
BY
(Authorized Official Signature and Title - see instructions)
(Signature instructions are on the back of this form)
www.irs.gov
Catalog Number 20755I
(Date signed)
Form 872 (Rev. 1-2001)
Instructions
If this consent is for income tax, self-employment tax, or FICA tax on tips and is made for any year(s)
for which a joint return was filed, both husband and wife must sign the original and copy of this form
unless one, acting under a power of attorney, signs as agent for the other. The signatures must
match the names as they appear on the front of this form.
If this consent is for gift tax and the donor and the donor's spouse elected to have gifts to third
persons considered as made one-half by each, both husband and wife must sign the original and
copy of this form unless one, acting under a power of attorney, signs as agent for the other. The
signatures must match the names as they appear on the front of this form.
If this consent is for Chapter 41, 42, or 43 taxes involving a partnership or is for a partnership return,
only one authorized partner need sign.
If this consent is for Chapter 42 taxes, a separate Form 872 should be completed for each potential
disqualified person, entity, or foundation manager that may be involved in a taxable transaction
during the related tax year. See Revenue Ruling 75-391, 1975-2 C.B. 446.
If you are an attorney or agent of the taxpayer(s), you may sign this consent provided the action is
specifically authorized by a power of attorney. If the power of attorney was not previously filed, you
must include it with this form.
If you are acting as a fiduciary (such as executor, administrator, trustee, etc.) and you sign this
consent, attach Form 56, Notice Concerning Fiduciary Relationship, unless it was previously filed.
If the taxpayer is a corporation, sign this consent with the corporate name followed by the signature
and title of the officer(s) authorized to sign.
Instructions for Internal Revenue Service Employees
Complete the Division Executive's name and title depending upon your division.
If you are in the Small Business /Self-Employed Division, enter the name and title for the
appropriate division executive for your business unit (e.g., Area Director for your area; Director,
Compliance Policy; Director, Compliance Services).
If you are in the Wage and Investment Division, enter the name and title for the appropriate division
executive for your business unit (e.g., Area Director for your area; Director, Field Compliance
Services).
If you are in the Large and Mid-Size Business Division, enter the name and title of the Director,
Field Operations for your industry.
If you are in the Tax Exempt and Government Entities Division, enter the name and title for the
appropriate division executive for your business unit (e.g., Director, Exempt Organizations; Director,
Employee Plans; Director, Federal, State and Local Governments; Director, Indian Tribal
Governments; Director, Tax Exempt Bonds).
If you are in Appeals, enter the name and title of the appropriate Director, Appeals Operating Unit.
The signature and title line will be signed and dated by the appropriate authorized official within your
division.
Catalog Number 20755I
Form 872 (Rev. 1-2001)