AGREEMENT LOCATOR NUMBER definition

AGREEMENT LOCATOR NUMBER. Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date

AGREEMENT LOCATOR NUMBER. Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY Agreement Review Cycle: Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS INSTRUCTIONS TO TAXPAYER If not already completed by an IRS employee, please fill in the information in the spaces provided on the front of this form for the following items: • Your employer’s name and address • Your name(s) (plus spouse’s name if the amount owed is for a joint return) and current address. • Your social security number or employer identification number. (Use the number that appears on the notice(s) you received.) Also, enter the last four digits of your spouse’s social security number if this is a joint liability. • Your home and work telephone number(s) • The complete name and address of your financial institution(s) • The kind of taxes you owe (form numbers) and the tax periods • The amount you owe as of the date you spoke to IRS • When you are paid • The amount you agreed to have deducted from your pay when you spoke to IRS • The date the deduction is to begin • The amount of any increase or decrease in the deduction amount, if you agreed to this with IRS; otherwise, leave BLANK After you complete, sign (along with your spouse if this is a joint liability), and date this agreement form, give it to your participating employer. If you received the form by mail, please give the employer a copy of the letter that came with it. Your employer should xxxx the payment frequency on the form and sign it. Then, your employer should return the parts of the form which were requested on your letter or return Part 1 of the form to the address shown in the “For assistance” box on the front of the form. If you need assistance, please call the appropriate telephone number below or write IRS at the address shown on the form. However, if you received this agreement by mail, please call the telephone number on the letter that came with it or write IRS at the address shown on the letter. For assistance, call: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 1-800-829-0922 (Individuals – Wage Earners)