Declaration Control Number (DCN)

00– – – 2 IRS Use Only—Do not write or staple in this space.

U.S. Individual Income Tax Declaration

8453-OL
Form

OMB No. 1545-1397

for an IRS e-file On-Line Return

Department of the Treasury
Internal Revenue Service
For the year January 1–December 31, 2001
䊳 See instructions on back.
2001
Your first name and initial Last name Your social security number
L
A
Use the B If a joint return, spouse’s first name and initial Last name Spouse’s social security number
IRS label. E
Otherwise, L
please
print or H
Home address (number and street). If a P.O. box, see instructions. Apt. no.
䊱 Important!
You must enter
䊱
type. E
R
your SSN(s) above.
City, town or post office, state, and ZIP code
E Daytime phone number
( )

Part I Tax Return Information (Whole dollars only)

1 Adjusted gross income (Form 1040, line 33; Form 1040A, line 19; Form 1040EZ, line 4) 1

2 Total tax (Form 1040, line 58; Form 1040A, line 36; Form 1040EZ, line 11) 2

3 Federal income tax withheld (Form 1040, line 59; Form 1040A, line 37; Form 1040EZ, line 8) 3

4 Refund (Form 1040, line 68a; Form 1040A, line 43a; Form 1040EZ, line 12a) 4

5 Amount you owe (Form 1040, line 70; Form 1040A, line 45; Form 1040EZ, line 13). See instructions 5
Part II Declaration of Taxpayer

6a I consent that my refund be directly deposited as designated in the electronic portion of my 2001 Federal income
tax return. If I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to receive
the refund.

b I do not want direct deposit of my refund or I am not receiving a refund.

c I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct
debit) entry to the financial institution account indicated in the tax preparation software for payment of my Federal
taxes owed on this return and/or a payment of estimated tax. I further understand that this authorization may apply
to subsequent Federal tax payments that I direct to be debited through the Electronic Federal Tax Payment System
(EFTPS). In order for me to initiate subsequent payments, I request that the IRS send me a personal identification
number (PIN) to access EFTPS. This authorization is to remain in full force and effect until I notify the U.S. Treasury
Financial Agent to terminate the authorization. To revoke a payment, I must contact the U.S. Treasury Financial
Agent at 1-888-353-4537 no later than 2 business days prior to the payment (settlement) date. I also authorize the
financial institutions involved in the processing of the electronic payment of taxes to receive confidential information
necessary to answer inquiries and resolve issues related to the payment.
If I have filed a balance due return, I understand that if the IRS does not receive full and timely payment of my tax liability,
I will remain liable for the tax liability and all applicable interest and penalties. If I have filed a joint Federal and state tax
return and there is an error on my state return, I understand my Federal return will be rejected.

Under penalties of perjury, I declare that the information I have given my intermediate service provider and/or transmitter
and the amounts in Part I above agree with the amounts on the corresponding lines of the electronic portion of my 2001
Federal income tax return. To the best of my knowledge and belief, my return is true, correct, and complete.

Sign
Here 䊳 Your signature Date 䊳 Spouse’s signature. If a joint return, both must sign. Date
For Paperwork Reduction Act Notice, see back of form. Cat. No. 15907C Form 8453-OL (2001)
Form 8453-OL (2001) Page 2
You may be able to file a completely Line Instructions If there is an amount on line 5 and you
paperless return! Your tax preparation check box 6b and are paying by check or
software contains information about Declaration Control Number (DCN). The money order, do not attach your payment to
using a self-select PIN instead of filing Form DCN is a 14-digit number assigned to your Form 8453-OL. Instead, mail it by
8453-OL. Or, you can visit the IRS Web Site return by your intermediate service provider April 15, 2002, with Form 1040-V to the IRS
at www.irs.gov. and/or transmitter. It should be included in at the applicable address shown on that form.
your acknowledgment message. Clearly type If you do not have a Form 1040-V, you may
General Instructions or print the DCN in the top left corner of Form be able to get it from your intermediate
service provider and/or transmitter. You can
8453-OL. The first two digits are always “00”.
also see your tax return instruction booklet for
Purpose of Form The next six digits are the electronic filer
other ways to get forms, or visit the IRS Web
identification number (EFIN). The next five
Use Form 8453-OL to: digits are the batch number and serial Site at www.irs.gov.
● Authenticate the electronic portion of your number. The “2” represents the year the If you check box 6c, you must ensure that
2001 Form 1040, 1040A, or 1040EZ, return is filed (2002). the following information relating to the
● Send any accompanying paper schedules Example. The EFIN is 509325. The batch financial institution account is provided in the
or statements, and number is 000. The serial number is 56. The tax preparation software.
● Provide your consent to directly deposit DCN is 00-509325-00056-2. ● Routing number.
any refund and/or authorize an electronic Name and Address. If you received a ● Account number.
funds withdrawal for payment of Federal taxes peel-off name and address label from the ● Type of account (checking or savings).
owed and/or a payment of estimated tax. IRS, put the label in the name area. Cross out ● Debit amount.
any errors and print the correct information.
Who Must File Add any missing items, such as your ● Debit date (date you want the debit to
apartment number. If you did not receive a occur).
If you are filing a 2001 Form 1040, 1040A, or
1040EZ through an intermediate service label, print or type the information in the Your electronically transmitted return will
provider and/or transmitter, you must file a spaces provided. not be considered complete, and therefore
signed 2001 Form 8453-OL with the IRS. If P.O. Box. Enter your box number only if the filed, unless and until the IRS receives your
you do not, you will not have filed a valid post office does not deliver mail to your home. signed Form 8453-OL. If a joint return, your
return for 2001, and we may not allow you to spouse must also sign.
Note: The address must match the address
file electronically next year. shown on your electronically filed return. Your signature allows the IRS to disclose to
Note: Do not send a copy of your your intermediate service provider and/or
Social Security Number (SSN). Be sure to transmitter the reason(s) for a delay in
Form 1040, 1040A, or 1040EZ. enter your SSN in the space provided on processing your return or refund. If you are
Form 8453-OL. If a joint return, list the SSNs
When and Where To File in the same order as the first names.
applying for a refund anticipation loan or
similar product, your signature also allows the
You must mail this form to the IRS on the
Part I—Tax Return Information IRS to advise your intermediate service
next working day after you have received
provider and/or transmitter if a refund offset
acknowledgment from your intermediate Line 5. Do not include any payment with may occur.
service provider and/or transmitter that the Form 8453-OL. The method of payment
IRS has accepted your electronically filed Refunds. Your refund should be issued within
depends on whether you check the box on
return. The address should be included in 3 weeks after the IRS has accepted your
line 6b or 6c. For details, see the instructions
your acknowledgment message. If not, mail return. However, some refunds may be
for Part II.
Form 8453-OL to the IRS at the applicable delayed because of compliance reviews to
address shown in the chart below. If you do Part II—Declaration of Taxpayer ensure that returns are accurate. Refund
not receive an acknowledgement, you must information is available on TeleTax. Call
Note: You must check all applicable boxes 1-800-829-4477.
contact your intermediate service provider on line 6.
and/or transmitter.

IF you live in . . . THEN mail Form 8453-OL to this address . . .

Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Receipt and Control Branch
Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and all Shipping and Receiving
APO and FPO addresses (except Asian/Pacific) 310 Lowell Street
Andover, MA 05501

Receipt and Control Branch

Shipping and Receiving
Illinois, Iowa, Kansas, Minnesota, Missouri, New Mexico, Oklahoma, Texas, Wisconsin
P.O. Box 1231
Austin, TX 78767-1231

Stop 2701
Florida, Indiana, Kentucky, Michigan, Ohio, South Carolina, West Virginia
Cincinnati, OH 45999

P.O. Box 1898

Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, Tennessee Attn: 8453-OL
Memphis, TN 38101

Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nebraska, Nevada, North Stop 6052
Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, and all Asian/Pacific APO and 1160 West 1200 South
FPO addresses Ogden, UT 84201

Paperwork Reduction Act Notice. We ask for unless the form displays a valid OMB control circumstances. The estimated average time
the information on this form to carry out the number. Books or records relating to a form or is 15 minutes. If you have comments concerning
Internal Revenue laws of the United States. You its instructions must be retained as long as their the accuracy of this time estimate or
are required to give us the information. We need contents may become material in the suggestions for making this form simpler, we
it to ensure that you are complying with these administration of any Internal Revenue law. would be happy to hear from you. You can write
laws and to allow us to figure and collect the Generally, tax returns and return information are to the Tax Forms Committee, Western Area
right amount of tax. confidential, as required by Internal Revenue Distribution Center, Rancho Cordova, CA
Code section 6103. 95743-0001. Do not send the form to this
You are not required to provide the address. Instead, see When and Where To File
information requested on a form that is subject The time needed to complete and file this on this page.
to the Paperwork Reduction Act form will vary depending on individual