Professional Documents
Culture Documents
Check here if you are a former Internal Revenue Service Employee, and enter the date you separated Enrollment Number:
from the Service / / .
2 Date of Birth
mm/dd/yyyy
For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 16233B Form 23 (Rev. 4-2017)
Form 23 (Rev. 4-2017) Page 2
If “Yes”, enter all CAF numbers assigned to you (attach additional pages, if necessary):
8 Are you current with your individual and business taxes, including any
corporate and employment tax obligations? Yes No If "NO", provide explanation.
NOTE: If you answered “Yes” to question 9, 10, 11 or 12, please describe on a separate page, the matter, including the date
of when the matter occurred, and provide any additional information about the matter that you would like us to consider.
13 Are you a CPA? Yes No If “Yes”, enter the states where you are licensed to practice.
14 Are you an Attorney? Yes No If “Yes”, enter the states where you are licensed to practice.
Signature Date
An intentionally false statement or omission identified with your application is a violation of Circular 230 10.51(a)(4) and 18 U.S.C. 1001
and may be grounds for suspension or disbarment from practice.
Form 23 (Rev. 4-2017) Page 3