Free Form 4419 (Rev. 6-2009) - Federal

(See Instructions on back)
Department of the Treasury ­ Internal Revenue Service

IRS Use Only

Form (Rev. 6-2009)

4419

Application for Filing Information Returns Electronically (FIRE)
Please type or print in BLACK ink.

OMB No. 1545-0387

1. Transmitter information Name

Mailing Address City State Zip

2. Person to contact about this request Name

Title Email address Telephone number

3. Employer Identification Number (EIN) (Social Security Number Not Permitted)

4. Foreign Transmitter without a TIN Yes

5. Tax year you wish to begin filing electronically

6. Will you be using your TCC only for transmitting requests for extension of time to file? 7. Type of Return To Be Reported (Check only types of forms you currently need to file)

Yes

No

Important: Form W-2 information is sent to the Social Security Administration (SSA) only. Do not use Form 4419 to request authorization to file this information electronically. Contact SSA for W-2 electronic filing information at 1-800-772-6270. Forms 1098, 1099, 3921, 3922, 5498 and W-2G 8. Check the appropriate box I have or will have software which will format my data into the IRS required format. I have a service provider who will file my data for me. Form 1042-S, Foreign Person's U.S. Source Income Subject to Withholding Form 8027, Employer's Annual Information Return of Tip Income and Allocated Tips

Note: For the forms referenced in Box 7, electronic filing does not refer to on-line fill-in forms.
Under penalties of perjury, I declare that I have examined this document, including any accompanying statements, and, to the best of my knowledge and belief, it is true, correct, and complete.

Name (type or print) 9. Person responsible for preparation of tax reports Signature

Title

Date Form 4419 (Rev. 6-2009)

Catalog Number 41639J

Form 4419 (Rev. 6-2009)

Page 2

General Instructions Paperwork Reduction Act Notice. We ask for the information on these forms to carry out the Internal Revenue Laws of the United States. 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 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 Code section 6103. The time needed to provide this information would vary depending on individual circumstances. The estimated average time is: Preparing Form 4419 . . . . . . . . . . . . . . . . . . . . . . 20 min. 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 the 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 FORM TO THIS OFFICE. Instead, see the instructions below on where to file. When completing this form, please type or print clearly in BLACK ink. Purpose of Form. File Form 4419 to request authorization to file any of the forms shown in Block 7 electronically. Please be sure to complete all appropriate blocks. If your application is approved, a five-character alpha-numeric Transmitter Control Code (TCC) will be assigned to your organization. If any information on the form should change, please write to IRS/Enterprise Computing Center - Martinsburg so we can update our database. It is not necessary to submit a new Form 4419. NOTE: Do NOT use Form 4419 to request authorization to file Forms W-2 electronically. Contact SSA at 1-800-772-6270 if you have any questions concerning the filing of Forms W-2.

Block 5 Enter the tax year that you wish to start filing electronically. Block 6 Indicate if you are requesting this Transmitter Control Code solely for filing electronic requests for an extension of time to file information returns. Block 7 Check the box next to all of the returns you will file with IRS electronically. A separate TCC will be assigned for each box checked in Block 7. Please make sure you submit your electronic files using the correct TCC. Thereafter, if you need to add any of the forms identified in Block 7, it will be necessary to submit another Form 4419 to IRS so another TCC can be assigned. Block 8 Indicate if your company will be filing your data with a software package or if you have contracted to have a service provider file your data for you. Note: The FIRE System does not provide an on-line fill-in option for the forms listed in Box 7. You must transmit your data in a specific format required by IRS. Block 9 The form must be signed and dated by an official of the company or organization requesting authorization to report electronically. Mailing Address: Send your Form 4419 to the address below: Internal Revenue Service Enterprise Computing Center - Martinsburg Information Reporting Program 230 Murall Drive Kearneysville, WV 25430 In order to ensure timely filing, submit Form 4419 at least 30 days before the due date of the return. If you prefer, the Form 4419 can be faxed toll-free to (877) 477-0572, but do not do both (faxing and mailing). The Form 4419 is subject to review before the approval to transmit electronically is granted and may require additional documentation at the request of IRS. If your application is approved, IRS will assign a TCC to your organization. We will not issue your TCC without a signed Form 4419, and we will not issue a TCC over the phone or by email. If you do not receive a reply from IRS within 30 days, contact us at the telephone number shown below. Do not submit any files until you receive your TCC. For further information concerning the filing of information returns with IRS electronically, you may access www.irs.gov for Publication 1220 for the current tax year. If you do not have internet access, you may contact the IRS Enterprise Computing Center - Martinsburg toll-free at (866) 455-7438 between 8:30 a.m. and 4:30 p.m. Eastern Standard Time.

Specific Instructions
Block 1 Enter the name and complete address of the organization that will submit the electronic files (transmitter). Block 2 Enter the name, title, email address (if available) and telephone number (with area code) of the person to contact about this application if IRS needs additional information. This should be a person who is knowledgeable about electronic filing of information returns. Block 3 Enter the Employer Identification Number (EIN) of the organization transmitting the electronic files. Social Security Numbers are not permitted. Block 4 If you are a foreign transmitter who does not have a nine-digit Taxpayer Identification Number, check this box.