Form 8453 U.S. INDIVIDUAL INCOME TAX DECLARATION Declaration Control Number (DCN) FOR ELECTRONIC FILING [ ]-[ ]-[ ]-[ ] Department of the Treasury For the year January 1-December 31, 1989 OMB No.1545-0936 Internal Revenue Service See instructions on back. 1989 --------------------------------------------------------------------------------------------------------------------------------------- Your first name and inital Last name Your social security number [___________________________________] [_________] If joint return, spouse's first name and initial Last name Spouse's social security number [___________________________________] [_________] Home address (number and street). (If a P.O. Box, see instructions.) Apt. no. Telephone number (optional) [___________________________________] (___)[___]-[____] City, town or post office, state and ZIP code For Paperwork Reduction Act [______________________][__][_________] Notice, see instructions. -------------------------------------------------------------------------------------------------------------------------------------- If the taxpayer's name changed during the past 3 years due to marriage, divorce, ect., and he or she filed a Federal income tax for such years using the former name, print the most recently used last name here. [____________________] --------------------------------------------------------------------------------------------------------------------------------------- PART I TAX RETURN INFORMATION (WHOLE DOLLARS ONLY) 1. Total income (Form 1040, line 23; Form 1040A, line 11; Form 1040EZ, line 3). . . . . . . . . . . . . . . . . . 1.[____________] 2. Total tax (Form 1040, line 55; Form 1040A, line 24; Form 1040EZ, line 7) . . . . . . . . . . . . . . . . . . . 2.[____________] 3. Federal Income tax withheld. (Enter from Forms W-2, W-2G, and W-2P only. See instructions.). . . . . . . . . . 3.[____________] 4. Refund (Form 1040, line 65; Form 1040A, line 27; Form 1040EZ, line 8). . . . . . . . . . . . . . . . . . . . . 4.[____________] --------------------------------------------------------------------------------------------------------------------------------------- PART II DIRECT DEPOSIT OF REFUND (SEE INSTRUCTIONS ON THE BACK OF THIS FORM.) ATTACH 5. Name of financial institution and, if applicable, branch name [___________________________________] COPY The RTN must begin with 01-12 or 21-32. B OF 6. Routing transit number (RTN). [_________] YOUR 7. Depositor account number (DAN). [_________________] FORMS 8. Type of depositor account: [_] Savings [_] Checking W-2, 9. Proof of account: [_] Check [_] Other W-2G, 10. Ownership of deposit account. Find the taxpayer's filing status and check the box that applies: AND * Single, head of house hold, or qualifying widow(er) . . . > [_] Self W-2P * Married filing joint return . . . . . . . . . . . . . . . > [_] Husband, [_] Wife, OR [_] Husband and Wife HERE. * Married filing seperate return. . . . . . . . . . . . . . > [_] Self OR [_] Husband and Wife --------------------------------------------------------------------------------------------------------------------------------------- PART III DECLIARATION OF TAXPAYER Under penalties of perjury, I declare that I have compared the information contained on my return with the information I have provided to my electronic return originator and that the amounts described in Part I above agree with the amounts shown on the corresponding lines of my 1989 Federal income tax return. To the best of my knowledge and belief, my return is true, correct, and complete. I consent that my return, including this declaration and accompanying schedules and statements, be sent to the Internal Revenue Service by my electronic return originator. If I have elected Direct Deposit, I declare that the information shown on lines 5 through 10 in Part II above is correct; I consent that my refund be directly deposited as designated in Part II above; and I authorize the Internal Revenue Service to inform my electronic return originator and/or the transmitter whether my request for Direct Deposit will be honored. If this return is a joint return and the refund is to be directly deposited, this is an irrevocable appointment of the other spouse as an agent to receive the refund. PLEASE SIGN >_____________________________________________________________________ >___________________________________________________ HERE Your signature Date Spouse's signature (if joint return, BOTH must sign) --------------------------------------------------------------------------------------------------------------------------------------- PART IV DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) I declare that I have reviewed the above taxpayer's return and that the entries on this form are complete and correct to the best of my knowledge. If Part II is completed, I declare that I have verified the taxpayer's proof of account and that this proof of account agreeswith the name shown on this declaration. I have obtained the taxpayer's signature before submitting this return to the IRS,have providedthe taxpayer with a copy of all forms and information to be filed with the IRS, and have followed all other requirements described in Pub. 1345, Revenue Procedure for Electronic Filing of Individual Income Tax Returns (Tax Year 1989). ELECTRONIC Check if not RETURN Date paid preparer [X] ORIGINATOR'S ERO's Check if Your social security number USE ONLY Signature>______________________________________________________ self-employed [_] [_________] ---------------------------------------------------------------------------------------------------------------------------------------- Firm's name (or yours if self-employed) [Automated Profit Mgmnt., Inc. ] E.I. No. [161352573] and address [164 Court Street, Binghamton, NY ] ZIP code [13901 ] FORM 8453 (1989) PAGE 2 ---------------------------------------------------------------------------------------------------------------------------------- PAPERWORK REDUCTION ACT NOTICE Taxpayers will need to know the DCN and originator. An acceptable proof of account We ask for this information to carry out the acceptance date of their electronic ownership ia s check, form, report, or the Internal Revenue laws of the United return to contact their local district other statement generated by the financial States . We need it to ensure that office to check on their refund. institution that has the taxpayers name taxpayers are complying with these laws routing transit number, and a depositor and to allow us to figure and collect EXAMPLE.--The EFIN is 509325. The batch account number preprinted on it. FINANCIAL the right amount of tax. number is 000. The serial number is 56. INSTITUTIONS WILL NOT ACCEPT PAYABLE- You are required to give us this inform- The DCN should be 00-509325-00056-0. THROUGH ACCOUNTS FOR DIRECT DEPOSIT. ation. NAME, ADDRESS, AND SOCIAL SECURITY LINE 10.--The account designated to The time needed to complete and file NUMBER recieve the direct deposit must be in the this form will vary depending on indivi- taxpayers name. The account cannot include dual circumstances. The estimated average If the taxpayer recieved a mailing label the name of any other person unless the time is: from the IRS, place the lable in the filing status on the return is married RECORD KEEPING . . . . . . . . . 20 MIN. name area. Cross out any errors and filing jointly or married filing print the correct information on the separately. If married filing jointly, the LEARNING ABOUT THE label. Add any missing items (such as account name can be in either or both LAW OR THE FORM. . . . . . . . . .3 MIN. apartment number). If the taxpayer did spouses' names. If married filing not recieve a label, print or type the separately, the account can be in the PREPARING THE FORM . . . . . . . 17 MIN. information in the space provided. taxpayer's name, or, it can be a joint account in both spouses' names. COPYING, ASSEMBLING, AND P.O. BOX.--If the post office does not SENDING THE FORM TO THE IRS. . . 20 MIN. deliver mail to the taxpayer's home, and PART III.--DECLARATION OF TAXPAYER the taxpayer has a P.O. box, enter the If you have comments concerning the P.O. box number instead of the address. The taxpayer's signature is required for accuracy of these time estimates or all returns. If PART II is completed, suggestions for making this form more NOTE: The address must match the address this signature also allows the IRS to simple, we would be happy to hear from shown on the electronically filed Form advise the electronic return originator you. You can write to the Internal 1040, Form 1040A, or Form 1040EZ. (ERO) and/or the transmitter when a Revenue Service, Washington, DC 202224, direct deposit election will not be Attention IRS Reports Clearance Officer, PART I.--TAX RETURN INFORMATION honored. T:FP; or the Office of Management and Budget, Paperwork Reductiion Progect LINE 3.--Enter the total Federal income If the electronic return originator (1545-0936), washington, DC 20503. tax withheld from Form(s) W-2, W-2g, (ERO) makes changes to the electronic and W-2P only. Do not include any return after Form 8453 has been signed by LINE-BY-LINE INSTRUCTIONS withholding from Form(s) 1099. the taxpayer but before it is transmitted, the ERO must have the taxpayer complete DECLARATION CONTROL NUMBER (DCN) and sign a corrected Form 8453 if either PART II.--DIRECT DEPOSIT OR REFUND of the following applies: The DCN is a 14-digit number assigned to each taxpayer account. The electronic Taxpayers can elect to have their refund * The total income (Form 8453,line 1) return originator (ERO) should enter this directly deposited by completing Part II differs from the amount on the electronic number as follows: return by more than $25, or LINE 6.--The routing transit number(RTN) BOXES ENTRY must contain 9 digits. If the RTN does * The total tax (Form 8453, line 2), or ----- ----- not begin with 01 through 12, or 21 the total refund (Form 8453, line 4), 1-2 File identification number through 32, The Direct Deposit request differs from the ammount on the electronic (always "00"). will be rejected. return by more than $5. 3-8 Electronic filer identification LINE 7.--The depositor account number For more information, get Pub. 1345. number (EFIN) assigned by IRS. (DAN) can contain up to 17 alphanumeric characters, Include hyphens, but omit PART IV.--DECLARATION OF ELECTRONIC 9-11 Batch number (000 to 999) spaces and special symbols. If fewer RETURN ORIGINATOR (ERO) assigned by the ERO. than 17 characters, enter the number from left to right and leave the unused The ERO's signature is required by the IRS 12-13 Serial number (00 to 99) boxes blank. if the ERO is not the paid preparer for assigned by the ERO. this tax return, the ERO must check the LINE 9.--To be eligible for Direct box provided. 14 Year digit (for 1990 the year of account ownership to their electronic digit is "0"). return. ----------------------------------------------------------------------------------------------------------------------------------
