SOCIETY FOR CREATIVE ANACHRONISM, (Clt)

PIN number for electronic signature PIN number for electronic signature that I have the authority to execute this form with respect to the tax matters/periods on line 3 above. corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify To revoke this tax information authorization, see the instructions on page 4. in effect and check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . not want to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain prior authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do If you do not want any copies of notices or communications sent to your appointee, check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . basis, check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6 . . . . . . . . . . . . . . . . . . . or Civil Penalty (see instr.) (see the instructions for line 3) (1040, 941, 720, etc.) (Income, Employment, Excise, etc.) Specific Tax Matters Year(s) or Period(s) Tax Form Number Type of Tax the tax matters listed on this line. Do not use Form 8821 to request copies of tax returns. Fax No. Telephone No. Address Check if new: Fax No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone No. . . . . . . . . . . . . . . . . . . . . . . . . . . . CAF No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name and address Form