EFTA01100240.pdf

NAME OF APPLICANT: TYPE OF APPLICATION: OFFICIAL USE ONLY NEW( Dates Received: EXTENSION( SMALL MANUFACTURER( MODIFICATION( Accepted as Complete: TRANSFER( APPLICATION FOR ECONOMIC DEVELOPMENT BENEFITS EFTA01100240  Application must be filed with the one (1) original and fourteen (14) bound copies. File with the Assistant Chief Executive Officer, Economic Development Commission, #4 King Street, Fredericksted, St. Croix 00840 or mailed to #116 King Street, Fredericksted, St. Croix 00840. APPLICATION NOTES: See Rules and Regulations for further guidance on filing application. Please provide as much information as possible. A complete application will speed processing. For information that is attached as an Appendix, please mark with an "X" in the space provided, and "O" if to be provided at a later date and "N.A." if not applicable. 2 EFTA01100241 1. CONTACT INFORMATION EIN #: NAICS Code A. Name of Applicant: B. Mailing Address: C. Phone: Fax: Email D. Plant/Facility Location: Island: Estate & Parcel No: E. Name of Local Attorney or Representative: Address: Phone: Fax: Email F. Please tell us how you learned of the EDC Program: 1. business contact( 2. attorney/tax advisor( ) 3. advertisement( ) 4. conference/expo( ) 5. website( ) 6. other--please explain( ) 2. BUSINESS INFORMATION A. Brief description of the type of Business to be undertaken by applicant in the USVI. (e.g. Assembly, Hotel, Boutique Hotel, Utility) 1. Category I( ) II( ) IIA( ) III( ) 2. Detailed description of the activities for which benefits are sought and narrative in support of application. (Include a business plan) Check if Attached, Appendix I ( ) 3. If applicant is a small business, attach a small business certification. Check if Attached, Appendix 2 ( ) 4. Please give information including full name, EIN#, place of business, resident agent and description of affiliate, subsidiary and/or parent business entities. (include an organizational chart, if applicable) Check if Attached, Appendix 3 ( ) B. Form of Business Organization: 1. Individual( ) 2. Corporation( ) 3. Partnership( ) 4. Limited Liability Corporation( ) S. Limited Liability Partnership( ) 6. Limited Liability Limited Partnership( ) 7. Other( ) 8: If Subsidiary of U.S. Corporation, Name of Parent Corporation and EIN( ) 3 EFTA01100242  1. Individual a. Country of citizenship: b. Date applicant became bonafide resident of the USVI: C. Applicant intends to remain a bonafide resident of the USVI? Yes( ) No( ) 2. Corporation a. If stockholders are individuals, stockholders full names (including first, middle, last and alias/nickname), Address, Date of Birth (including month, day and year), Place of Birth and Social Security Number or Country ID, for stockholders owning 5% or more of the corporation. Check if Attached, Appendix 4 ( ) b. If stockholder is a corporation or other entity, provide entity information and specify full names (including first, middle, last and alias/nickname) of directors, principals and officers, for stockholders owning 5% or more of the corporation. Check if Attached, Appendix S ( ) c. Date of incorporation: Place of incorporation: d. Copy of Ankles of Incorporation certified by the Lt. Governor's Office. Check if Attached, Appendix 6 ( ) e. "Certificate of Good Standing" from Lt. Governor's Office certifying that all required annual reports have been filed and franchise taxes paid. Check if Attached, Appendix 7 ( ) f. In case of a foreign (non V.I.) corporation, attach evidence that the Corporation is authorized to do business in the USVI. Check if Attached, Appendix 8 ( ) 4 EFTA01100243 3. Partnership a. Full names (including first, middle, last and alias/nickname), residence, social security number, date of birth, place of birth, occupation and citizenship of each partner owning 5% or more of the partnership and those who are or will be bonafide resident seeking to claim dividends and interest withholding exemptions. VI residents must give date when his or her residency commenced. 1. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSWCOUNTRY ID NO. DATE OF BIRTH 2. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSWCOUNTRY ID NO. DATE OF BIRTH 3. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSWCOUNTRY ID NO. DATE OF BIRTH 4. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSWCOUNTRY ID NO. DATE OF BIRTH 5. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSN/COUNTRY ID NO. DATE OF BIRTH b. Attach a copy of partnership agreement filed at the Lt. Governor's Office and the internal agreement between partners. Check ij Attached, Appendix 9 ( ) c. If a partner is a corporation, submit all of the information required of a corporation (Section "B") for each applicant. Check if Attached, Appendix 10 ( ) d. If a partner is a LLC, submit all of the information required of a Limited Liability Corporation. Check if Attached, Appendix 11 ( ) e. If a partner is a LLP, submit all of the information required of a Limited Liability Partnership. Check if Attached, Appendix 12 ( ) f. If a partner is a LLLP, submit all of the information required of a Limited Liability Partnership. Check if Attached, Appendix 13 ( ) 5 EFTA01100244  4. Limited Liability Entries a. Full names (including first, middle, last and alias/nickname), residence, social security number, date of birth, place of birth, occupation and citizenship of each member/partner owning 5% or more of the equitable interest in the business and those who are or will be a bonafide resident seeking to claim dividends and interest withholding exemptions. VI residents must give date when his or her residency commenced. 1. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSN/COUNTRY ID NO. DATE OF BIRTH 2. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSWCOUNTRY ID NO. DATE OF BIRTH 3. NAME CITIZENSHIP OWNEFtSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSN/COUNTRY ID NO. DATE OF BIRTH 4. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION 55N/COUNTRY ID NO. DATE OF BIRTH 5. NAME CITIZENSHIP OWNERSHIP% ADDRESS DATE OF V.I. RESIDENCY OCCUPATION SSN/COUNTRY ID NO. DATE OF BIRTH b. Agreement of LLLP: General Partner: Check if Attached, Appendix 14 ( ) c. Statement of Qualification Check if Attached, Appendix 1S ( ) d. Certificate of Limited Partnership Check if Attached, Appendix 16 ( ) e. Article of Organization Check if Attached, Appendix 17 ( ) f. Certificate of Existence: General Partner: Check if Attached, Appendix 18 ( ) g. Agreement between General 8c Limited Partners Check if Attached, Appendix 19 ( ) h. If a member/partner is an entity, submit all of the information required of such entity Check if Attached, Appendix 20 ( ) 6 EFTA01100245 3. EMPLOYMENT A. Employment and payroll information 1. Summary FULLTIME EMPLOYMENT PRESENT AFTER FIRST 12 MONTHS COMMENCEMENT OF BENEFITS POSMON CLASSIFICATION NO. ANNUAL WAGES NO. ANNUAL WAGES** HOURLY WORKERS RESIDENT S S OTHER S S CLERICAL RESIDENT S S OTHER S S TECHNICAL RESIDENT S S OTHER S S MANAGEMENT/SUPERVISORY RESIDENT S S OTHER S S Please attach a list of job titles and salaries Check if Attached, Appendix 21 ( ) 2. How many employees will be Non-Virgin Islands residents at the commencement of benefits? Check if Attached, Appendix 21 ( ) 3. How many employees will be Non-Virgin Islands residents at the time of hire? Check if Attached, Appendix 22 ( ) 4. If applicant is or will be employing non-residents, attach a copy of Comprehensive training plan approved by the Commissioner of Labor. Check if Attached, Appendix 23 ( ) S. How many employee positions will be filled by owners, partners or members? Please list job titles and functions. Check if Attached, Appendix 24 ( ) 6. Attach copies of most recent payrolls to include name, title, ss#, job, and salary. Check if Attached, Appendix 25 ( ) 7. Has the applicant, parent, affiliate or subsidiary entities had any unresolved labor problems during the past two (2) years? Yes( ) No( ) If "yes", attach a statement as to the nature of the problem. Check if Attached, Appendix 26 ( ) 8. Attach copy of Organizational Chart. Check if Attached, Appendix 27 ( ) 9. Employee benefit Plan. Check if Attached, Appendix 28 ( ) 7 EFTA01100246  4. INVESTMENT & PROCUREMENT A. Proposed Initial Capital Investment New Applicant $ Extension/Modification $ Small Business $ Date of Commencement of Investment Date of Completion of Investment B. If Business Operations Include Manufacturing, Principal Raw Materials And Components To Be Utilized In Process: DESCRIPTION SOURCE* ANNUAL DOLLAR VOLUME VALUE AS % OF FINISH PRODUCT *INDICATE WHETHER V.I., U.S , OR NAME OF FOREIGN COUNTRY. C. In the event the applicant is engaged in manufacturing requiring duty free entry to the U.S., Attach U.S. customs ruling for favorable treatment under headnote 3(a) (19 USC 1202). Check if Attached, Appendix 29 ( ) D. Principal revenue source; indicate percent to: V.I. % U.S. %; Foreign (name of country/countries) Check if Attached, Appendix 30 ( ) E. Machinery and Equipment: DESCRIPTION DATE OF ACQUISITION PURCHASE PRICE `LEASE COST *PLEASE SUBMIT COPY OF LEASE AND DOCUMENTATION ATTESTING TO THE FAIR MARKET VALUE OF EQUIPMENT TO BE LEASED. Check (Attached, Appendix 31 ( ) 8 EFTA01100247  F. Land and Buildings: LOCATION: INMAL PLANNED EXPANSION LAND AREA (ACRES/SO.FT.) LAND VALUE (IF OWNED) S $ DATE PURCHASED OR RENTED NUMBER OF BUILDINGS: AREA (ACRES/SCLFT.) BUILDING VALUE (IF OWNED) S S ANNUAL RENT (SUBMIT LEASE) S S DATE PURCHASED OR RENTED b. If land and/or building are leased, attach copy of lease(s) Check if Attached, Appendix 32 ( ) c. If facilities are not yet owned/leased, description of facilities needed for business, (i.e. # of square footage, etc.) Check if Attached, Appendix 33 ( ) G. Indicate whether the applicant will utilize any facilities or locations in common with another person or company. Yes( ) No( ) If "Yes", list such facilities and locations, their value (if owned) and percentage used by each occupant. User 1 User 2 NAME NAME 9 EFTA01100248  5. FINANCIAL A. FINANCIAL INFORMATION Please submit the following if applicable: 1. Applicant must obtain a Bank reference (s) letter, provide a list of all bank accounts and the names of all authorize signatures on the accounts. Check if Attached, Appendix 34 ( ) la. If capitalization is through individual or entities, please provide a financial institution letter indicating verification of source of investment/capitalization. Check if Attached, Appendix 35 ( ) 2. Certified copies of Profit and Loss statements and balance sheets for the past three (3) years; if entity (or similar prior entity) has been in operation prior to application. Check if Attached, Appendix 36 ( ) 3. Projected income and expense statements for five (5) years which have been signed by principals. (Use attached example format or equivalent. See page 14.) Check if Attached, Appendix 37 ( ) 4. Beginning balance sheet nust be signed by principals. Check if Attached, Appendix 38 ( ) 5. If applicant or a shareholder/partner/member owning more than 5% or more of applicant is a publicly traded entity; copies of the annual report of same. Check if Attached, Appendix 39 ( ) 6. If entity is a pass-through entity, provide for owners who are/were VI residents. Statement as to the manner in which the investment has been, or will be financed together with names and addresses of persons or companies providing the financing. Check if Attached, Appendix 40 ( ) 10 EFTA01100249 6 TAX INFORMATION A. Letter from V.I. Bureau of Internal Revenue indicating status of tax obligations. (Not required for corporations existing less than one (1) year; if operations has not commenced) Check if Attached, Appendix 41 ( ) B. Copies of applicant entity Federal (IRS) or V.I. income tax returns for the past three (3) years. Check if Attached, Appendix 42 ( ) C. Copies of Federal (IRS) or V.I. income tax returns for the past three (3) years for beneficiary owners. Check if Attached, Appendix 43 ( ) 7 ADDITIONAL INFORMATION A. Applicant must obtain a letter from the V.I. Department of Planning and Natural Resources stating compliance with ecological, environmental and planning laws and regulations. Check if Attached, Appendix 44 ( ) B. If the property of facility adjoins beach or shoreline attach copy of easement or lease recorded with recorder of deeds with public easement provisions. Check if Attached, Appendix 45 ( ) C. If applicant is approved, does applicant intend to conduct any business not eligible for benefits? Yes( ) No( ) If "yes", attach explanation and the nature of such business. Check if Attached, Appendix 46 ( ) D. Please Attach your management training program plan. Check if Attached, Appendix 47 ( ) E. Explain and give evidence of your educational assistance program Check if Attached, Appendix 48 ( ) 11 EFTA01100250  8 BACKGROUND INFORMATION A. Indicate whether applicant, or any of its stockholders or partners have, or have had, any proprietary interest in any other enterprise which is or has been a beneficiary under the V.I. Economic Development Program. Please answer questions B-E for all applicant(s), entity partners, owners, directors or officers of corporation and beneficial owners. Yes( ) No( ) If "yes" explain below. NAME NAME OF BUSINESS TYPE OF BUSINESS B. Has any entity in which you, or your spouse, is/was a &rector, officer, partner or an owner of a 5% or greater interest ever had any license, permit, or certificate issued by a governmental agency in any jurisdiction denied, suspended, revoked, or subject to any conditions? Yes( ) No( ) If "Yes" please explain. Check if Attached, Appendix 49 ( ) C. Have you ever been arrested or charged with any crime or offense in any jurisdiction? Yes( ) No( ) If "yes" please explain. Check if Attached, Appendix 50 ( ) D. Have you ever been the subject of an investigation conducted by any governmental agency/organization, court, commission, committee, grand jury or investigatory body (local, state, county, provincial, federal, national, ect.) other than in response to a traffic summons? Yes( ) No( ) If "yes" please provide the name and address of court or other agency, nature of proceeding or investigation date, whether testimony given and if so what date, and approximate time period of investigation. Check if Attached, Appendix Si ( ) E. Have any of the beneficial owners ever been adjudicated or filed a petition for any type of bankruptcy, insolvency or liquidation under any bankruptcy or insolvency law in any jurisdiction? Check if Attached, Appendix 52 ( ) 12 EFTA01100251 9. EXTENSIVE, MODIFICATION AND TRANFER APPLICANTS A. Provide clearance certificate from the EDC Compliance Unit. B. Extension applicants. All extension applicants should provide the following: 1. Certificate showing the liability of its previous business. Check if Attached, Appendix 53 ( ) 2. Indicate the specific benefits which applicant is seeking. Check if Attached, Appendix 54 ( ) 3. A certificate from the Commissioner of Labor stating the applicant is in compliance with all labor laws, codes and regulations. Check if Attached, Appendix 55 ( ) 4. A statement showing the percentage level, effective date and termination date of each type of benefit previously enjoyed by the applicant. Check if Attached, Appendix S6 ( ) 5. In the case of a hotel, timeshare, guesthouse, condo/hotels, boutique hotel, etc, a statement from the V.I. Bureau of Economic Research showing that the applicant is current in reporting the hotel, timeshare, guesthouse, condo/hotels, boutique hotel, etc. occupancy on a monthly and annual basis and visitor origin data on annual basis, for a two year period ending no more than five months prior to the date of the application. Check if Attached, Appendix 57 ( ) C. Transfer applicants: In addition to the information required in items 1-9 above, transfer applications (as defined in section 719 title 29 VIC) shall contain the date on which the applicant wishes the effective date of the transfer of benefits. Check if Attached, Appendix 58 ( ) D. Exempt support businesses: In addition to the information required in items 1-9 above, all exempt support business applicants shall provide a statement from the commissioner of insurance and copy of license to operate in the V.I. as an "exempt support business". Check if Attached, Appendix 59 ( ) 13 EFTA01100252 APPENDIX 37 Income Et Expense Statements * Five Year Projection** Tear 1 Year 1 Year 3 Year 4 Year 5 MU 5 years REVENUES(Itemize): TOTAL REVENUE Total Cost of Sales Gross Margin OPERATING EXPENSES: LABOR COSTS(Full-time Employment) Salaries and Wages Payroll Taxes TOTAL LABOR COSTS LOCAL PURCHASE OF GOODS & SERVICE Utilities Raw Materials Freight Charges Insurance Other (Specify) TOTAL LOCAL EXPENSES EXPENSES OTHER THAN LOCAL: Raw Materials Advertising/Promotion Supplies Depreciation Other (Specify) TOTAL NON-LOCAL EXPENSES TOTAL OPERATING EXPENSES NET PROFIT BEFORE TAXES *SAMPLE FORMAT '"APPLICATION WILL NOT BE PROCESSED WITHOUT THE REQUESTED INFORMATION Application must be filed with one (1) original and fourteen (14) bound copies. File with the Director of Applications, Economic Development Commission 84 King Street, Fredericksted, St, Croix 00840. EFTA01100253 TRUTH STATEMENT on the basis of information presented in this application and the accompanying attachments, applicant requests the Industrial Development Commission grant to the applicant, Economic Development Commission benefits provided by the title 29 chapter 12 of the Virgin Islands code as amended. "Under penalties and pain of perjury I hereby certify that all the above information, as well as accompanying documents, are true and complete to the best of my knowledge, information and belief If information submitted changes I understand that I am obligated to inform the Economic Development Commission." NAME OF APPLICANT AUTHORIZED SIGNATURE TITLE DATE Subscribed and sworn to before me this day of , 20 Notary Public Seal or Authority of Notary RELEASE AUTHORIZATION To All Courts, Probation Departments, Selective Service Boards, Employers, Educational Institutions, Banks, Financial and Other Such Institutions, and MI Governmental Agencies — federal, state and local, without exception, both foreign and domestic. On Behalf of (Name of Entetprise) (Name of President, office); partner or sole proprietor) have authorized the Virgin Islands Economic Development Commission or its designee to conduct a full investigation into the background of the said enterprise. Therefore, you are hereby authorized to release any and all information pertaining to the said enterprise, documentary otherwise, as requested by any employee or agent of the Virgin Islands Economic Development Commission or its designees, provided that he or she certifies to you that said enterprise has an application pending before the Economic Development Commission or that said enterprise is presently a licensee or registrant requirement to be qualified under the provisions of Title 29 VIC Chapter 12 701-726. This authorization shall supersede and countermand any prior request or authorization to the contrary. A photo static copy of this authorization will be considered as effective and valid as the original. Subscribed and sworn to before me this day of , 20 Signature EFTA01100254  Fom8821 Ni ises-nes Tax Information Authorization Forte Use 0* *sad erf. (Rev. August 2008) la Do not sign this form unless all applicable lines have been completed. kw* Deparenent of me Treasury internal Revenue Service ► Do not use this form to request a copy or transcript of your tax return. Terernore I Instead, use Form 4506 or Form 4506-1. A.M001 0. 1 Taxpayer Information. Taxpayer(s) must sign and date this form on line 7 Taxpayer narne(s) and address (type a pang Social security number(s) Employer identification number DayUrno *soon* number Plan number (l applicable) ( 2 Appointee. If you wish to name more than one appointee, attach a list to this form. Name and address CAF No. Telephone No. Fax No. Check if new: Address 0 Telephone No. 0 Fax No. 0 3 Tax matters. The appointee s authorized to inspect and/or receive confidential tax information in any office of the IRS for the tax matters listed on this line. Do not use Form 8821 to request copies of tax returns. (a) 0:1) fc) Type of Tax Tax Form Number Year(s) or Period(s) (d) (Income, Employment, Excise, etc.) (1040, 941, 720, (see the instructions for line 3) Specific Tax Matters (see Instr.) or Civil Penalty etc.) 4 Specific use not recorded on Centralized Authorization File (CAF). U the tax information authorization is for a specific use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6 . ► 0 5 Disclosure of tax Information (you must check a box on line 5a or 5b unless the box on line 4 is checked): a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing basis, check this box ► 0 b If you do not want any copies of notices or communications sent to your appointee, check this box . . . . ► 0 6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect and check this box ► 0 To revoke this tax information authorization, see the instructions on page 4. 7 Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign. If signed by a corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute this forrn with respect to the tax matters/periods on line 3 above. ▪ IF NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED. ▪ DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE. Signature Date Sinature Date Print Name Tiler td Prnt Nuns Title 01 applicable) *Pk") ❑ El ❑ El ❑ PIN number for electronic signature OOOOOPM number for electronic signature 16 For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 11596P Form 8821 (Rev. 8-2008) EFTA01100255 Form 8821 (Rev. 8-2008) General Instructions Use Form 4506, Request for Copy of Tax Return, to get a copy of your tax return. Section references are to the Internal Revenue Code Use Form 4506-T, Request for Transcript of Tax unless otherwise noted. Return, to order: (a) transcript of tax account information and (b) Form W-2 and Form 1099 series Purpose of Form information. Form 8821 authorizes any individual, corporation, firm, Use Form 56, Notice Concerning Fiduciary organization, or partnership you designate to inspect Relationship, to notify the IRS of the existence of a and/or receive your confidential information in any fiduciary relationship. A fiduciary (trustee, executor, office of the IRS for the type of tax and the years or administrator, receiver, or guardian) stands in the periods you list on Form 8821. You may file your own position of a taxpayer and acts as the taxpayer. tax information authorization without using Form 8821, Therefore, a fiduciary does not act as an appointee but it must include all the information that is requested and should not file Form 8821. If a fiduciary wishes to on Form 8821. authorize an appointee to inspect and/or receive Form 8821 does not authorize your appointee to confidential tax information on behalf of the fiduciary, Form 8821 must be filed and signed by the fiduciary advocate your position with respect to the federal tax acting in the position of the taxpayer. laws; to execute waivers, consents, or closing agreements; or to otherwise represent you before the When To File IRS. If you want to authorize an individual to represent you, use Form 2848, Power of Attorney and Form 8821 must be received by the IRS within 60 days Declaration of Representative. of the date it was signed and dated by the taxpayer. Where To File Chart IF you live in ... THEN use this address . .. Fax Number Alabama, Arkansas, Connecticut, Delaware, Internal Revenue Service 901-546-4115 District of Columbia, Florida, Georgia, Memphis Accounts Management Center Illinois, Indiana, Kentucky, Louisiana, Maine, PO Box 268, Stop 8423 Maryland, Massachusetts, Michigan, Memphis, TN 38101-0268 Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, or West Virginia Alaska, Arizona, California, Colorado, Internal Revenue Service 801-620-4249 Hawaii, Idaho, Iowa, Kansas, Minnesota, 1973 N. Rulon White Blvd. MS 6737 Missouri, Montana, Nebraska, Nevada, Ogden, UT 84404 New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wisconsin, or Wyoming All APO and FPO addresses, American Internal Revenue Service 215-516-1017 Samoa, nonpermanent residents of Guam International CAF DP: SW-311 or the Virgin Islands—, Puerto Rico (or if 11601 Roosevelt Blvd. excluding income under section 933), a Philadelphia, PA 19255 foreign country, U.S. citizens and those filing Form 2555, 2555-EZ, or 4563. 'These numbers may change without notice. "Permanent residents of Guam should use Department of Taxation, Government of Guam, P.O. Box 23607, GMF, GU 96921; permanent residents of the Virgin Islands should use: V.I. Bureau of Internal Revenue, 9601 Estate Thomas Charlotte Amalie, St. Thomas, V.I. 00802. 17 EFTA01100256  Form 8821 (Rev. 8-2008) Where To File Specific Instructions Generally, mail or fax Form 8821 directly to the IRS. See the Where To File Chart on page 2. Exceptions are listed below. Line 1. Taxpayer Information If Form 8821 is for a specific tax matter, mail or fax it to Individuals. Enter your name, TIN, and your street address the office handling that matter. For more information, see the in the space provided. Do not enter your appointee's address instructions for line 4. or post office box. If a joint return is used, also enter your spouse's name and TIN. Also enter your EIN if applicable. Your representative may be able to file Form 8821 electronically with the IRS from the IRS website. For more Corporations, partnerships, or associations. Enter the information, go to www.irs.gov. Under the Tax Professionals name. EIN, and business address. tab, click on e-services-Online Tools for Tax Professionals. If Employee plan or exempt organization. Enter the name, you complete Form 8821 for electronic signature address, and EIN of the plan sponsor or exempt authorization, do not file a Form 8821 with the IRS. Instead, organization, and the plan name and three-digit plan number. give it to your appointee, who will retain the document. Trust. Enter the name, title, and address of the trustee, Revocation of an Existing Tax Information and the name and EIN of the trust. Authorization Estate. Enter the name, title, and address of the decedent's executor/personal representative, and the name If you want to revoke an existing tax information and identification number of the estate. The identification authorization and do not want to name a new appointee. number for an estate includes both the EIN, if the estate has send a copy of the previously executed tax information one, and the decedent's TIN. authorization to the IRS, using the Where To File Chart on page 2. The copy of the tax information authorization must Line 2. Appointee have a current signature and date of the taxpayer under the original signature on line 7. Write "REVOKE" across the top Enter your appointee's full name. Use the identical full name of Form 8821. If you do not have a copy of the tax on all submissions and correspondence. Enter the nine-digit information authorization you want to revoke, send a CAF number for each appointee. If an appointee has a CAF statement to the IRS. The statement of revocation or number for any previously filed Form 8821 or power of withdrawal must indicate that the authority of the appointee attomey (Form 2848), use that number. If a CAF number has is revoked, list the tax matters and periods, and must be not been assigned, enter "NONE," and the IRS will issue one signed and dated by the taxpayer or representative. If the directly to your appointee. The IRS does not assign CAF taxpayer is revoking, list the name and address of each numbers to requests for employee plans and exempt recognized appointee whose authority is revoked. When the organizations. taxpayer is completely revoking authority, the form should If you want to name more than one appointee, indicate so state "remove all years/periods" instead of listing the specific on this line and attach a list of appointees to Form 8821. tax matters, years, or periods. If the appointee is withdrawing, list the name, TIN, and address (if known) of the Check the appropriate box to indicate if either the address, taxpayer. telephone number, or fax number is new since a CAF number was assigned. To revoke a specific use tax information authorization, send the tax information authorization or statement of revocation to the IRS office handling your case, using the Line 3. Tax Matters above instructions. Enter the type of tax, the tax form number, the years or periods, and the specific tax matter. Enter "Not applicable," Taxpayer Identification Numbers (TINs) in any of the columns that do not apply. TINs are used to identify taxpayer information with For example, you may list "Income, 1040" for calendar year corresponding tax returns. It is important that you furnish "2006" and "Excise, 720" for "2006" (this covers all quarters correct names, social security numbers (SSNs), individual in 2006). For multiple years or a series of inclusive periods, taxpayer identification numbers (ITINs), or employer including quarterly periods, you may list 2004 through (thru identification numbers (EINs) so that the IRS can respond to or a hyphen) 2006. For example, "2004 thru 2006" or "2nd your request. 2005-3rd 2006." For fiscal years, enter the ending year and month, using the YYYYMM format. Do not use a general Partnership Items reference such as "All years," "All periods," or "All taxes." Any tax information authorization with a general reference will Sections 6221-6234 authorize a Tax Matters Partner to be returned. perform certain acts on behalf of an affected partnership. You may list the current year or period and any tax years Rules goveming the use of Form 8821 do not replace any or periods that have already ended as of the date you sign provisions of these sections. the tax information authorization. However, you may include on a tax information authorization only future tax periods that Representative Address Change end no later than 3 years after the date the tax information If the representative's address has changed, a new Form authorization is received by the IRS. The 3 future periods are 8821 is not required. The representative can send a written determined starting atter December 31 of the year the tax notification that includes the new information and their information authorization is received by the IRS. You must signature to the location where the Form 8821 was filed. enter the type of tax, the tax form number, and the future year(s) or period(s). If the matter relates to estate tax, enter the date of the decedent's death instead of the year or period. 18 EFTA01100257 Form 8821 (Rev. 8-2008) In column (d), enter any specific information you want the All others. See section 6103(e) if the taxpayer has died, is IRS to provide. Examples of column (d) information are: lien insolvent, is a dissolved corporation, or if a trustee, guardian, information, a balance due amount, a specific tax schedule, executor, receiver, or administrator is acting for the taxpayer. or a tax liability. For requests regarding Form 8802, Application for United States Residency Certification, enter "Form 8802" in column Privacy Act and Paperwork Reduction Act (d) and check the specific use box on line 4. Also, enter the Notice appointee's information as instructed on Form 8802. We ask for the information on this form to carry out the Note. If the taxpayer is subject to penalties related to an Internal Revenue laws of the United States. Form 8821 is individual retirement account (IRA) account (for example, a provided by the IRS for your convenience and its use is penalty for excess contributions) enter, "IRA civil penalty' on voluntary. If you designate an appointee to inspect and/or line 3, column a. receive confidential tax information, you are required by section 6103(c) to provide the information requested on Form Line 4. Specific Use Not Recorded on CAF 8821. Under section 6109. you must disclose your social security number (SSN), employer identification number (EIN), Generally, the IRS records all tax information authorizations or individual taxpayer identification number (ITIN). If you do on the CAF system. However, authorizations relating to a not provide all the information requested on this form, we specific issue are not recorded. may not be able to honor the authorization. Check the box on line 4 if Form 8821 is filed for any of the The IRS may provide this information to the Department of following reasons: (a) requests to disclose information to loan Justice for civil and criminal litigation, and to cities, states, companies or educational institutions, (b) requests to the District of Columbia, and U.S. possessions to carry out disclose information to federal or state agency investigators their tax laws. We may also disclose this information to other for background checks. (c) application for EIN, or (d) claims countries under a tax treaty, to federal and state agencies to filed on Form 843, Claim for Refund and Request for enforce federal nontax criminal laws, or to federal law Abatement. If you check the box on line 4, your appointee enforcement and intelligence agencies to combat terrorism. should mail or fax Form 8821 to the IRS office handling the matter. Otherwise, your appointee should bring a copy of You are not required to provide the information requested Form 8821 to each appointment to inspect or receive on a form that is subject to the Paperwork Reduction Act information. A specific-use tax information authorization will unless the form displays a valid OMB control number. Books not revoke any prior tax information authorizations. or records relating to a form or its instructions must be retained as long as their contents may become material in Line 6. Retention/Revocation of Tax the administration of any Internal Revenue law. Information Authorizations The time needed to complete and file this form will vary Check the box on this line and attach a copy of the tax depending on individual circumstances. The estimated information authorization you do not want to revoke. The average time is: Recordkeeping, 6 min.; Learning about the filing of Form 8821 will not revoke any Form 2848 that is in law or the form, 12 min.; Preparing the form, 24 min.; effect. Copying and sending the form to the IRS, 20 min. If you have comments concerning the accuracy of these Line 7. Signature of Taxpayer(s) time estimates or suggestions for making Fon-n 8821 simpler,