Free Form 8569 (Rev. 4-2006) - Federal

Geographic Availability Statement
Paperwork Reduction Act Notice: This form is used in considering applicants for the Senior Executive Service Candidate Development Program and other executive positions. Your response is voluntary; however, your failure to provide this information could effect your consideration for this program. This signed statement will remain the minimum area of availability and will be used for future job placement consideration. Employees must secure the approval of the Executives Resources Board for any change in their area of availability. Based upon your experience and prior assignments, you will be considered for any Board covered position located in the area of your geographic availability. The cities listed below are not all inclusive but are intended to provide you with a general idea of where IRS offices do or may exist.

OMB No. 1545-0973

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Internal Revenue Code Section 6103. The time needed to complete the geographic availability statement is twenty minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6406, Washington, DC 20224. DO NOT send the completed Geographic Availability Statement to this office.

Availability for Headquarter Operations in Washington, DC and/or Atlanta is required. I am available for all locations. I am available for only those locations marked below. (You must mark all locations for which you are available. If you are only available for Washington, DC and/or Atlanta, you must mark which one or both.) Atlanta GA Andover MA Austin TX Baltimore MD Boston MA Brookhaven NY Brooklyn NY Chicago IL Cincinnati OH Dallas TX Denver CO Detroit MI Fresno CA Ft. Lauderdale FL Greensboro NC Hartford CT Houston TX Indianapolis IN Jacksonville FL Kansas City MO Laguna Niguel CA Los Angeles CA Manhattan NY Martinsburg WV Memphis TN Nashville TN Newark NJ New Orleans LA Oakland CA Ogden UT Philadelphia PA Phoenix AZ San Francisco CA Seattle WA St. Louis MO St. Paul MN Washington DC Metropolitan Area Remarks

Name (Please type) Signature
Return completed form to Internal Revenue Service Attn: Executive Services Division OS:HC:S Room 3511 1111 Constitution Ave., NW Washington, DC 20224
Catalog Number 63618S

Date signed

Form 8569 (Rev. 4-2006)

www.irs.gov

Department of the Treasury-Internal Revenue Service