Form 2678

Department of the Treasury - Internal Revenue Service

Employer Appointment of Agent

Under Section 3504 of the Internal Revenue Code
(For use by employers or payers)

OMB Number

1545-0748

(Rev. June 1997)

1. To

Director

Service Center

Instructions

Employer or Payer: Please complete this form and give it to the agent.

Agent: Please attach a letter requesting authority to do either all that is required of the employer for wages you pay on the employer's behalf or all that is required of the payer for requirements of backup withholding. (See applicable Revenue Procedures 70-6 or 84-33.) Forward both the letter of request and Form 2678 to the Director of the Internal Revenue Service Center where you file your returns. (See reverse side for addresses.)

Note: Rev. Proc. 70-6 is available in Publication 1271 and Rev. Proc. 84-33 is available in Publication 1272,

	

	

3. Employer's or Payer's address (Number and street, city, town or post office, State and ZIP code)

6. Agent's address (Number and street, city, town or post office, State and ZIP code)

8. Effective for (Check the box or boxes that apply)

Employment taxes (Rev. Proc. 70-6)

Backup withholding (Rev. Proc. 84-33)

9. If filing under Rev, Proc. 70-6, does this apply to all employees?

Yes

No

10. Effective date of appointment by employer or payer

Under section 3504 of the Internal Revenue Code, please authorize this agent to do all that is required under (Check the one(s) that apply)

Chapter 21 (FICA)

Chapter 22 (Railroad Retirement)

Chapter 24-

Withholding and/or

Backup withholding

Chapter 25 (General Provisions) of Subtitle C

The agent named above has been appointed either to pay wages for employers and/or report and deposit backup withholding amounts for payers. This appointment is effective on the date shown in Item 10.

It is understood that the agent and the employer or payer are subject to all provisions of law and regulations (including penalties) which apply to employers or payers.

Signature of employer or payer

Date

Title of signing official (Indicate whether the person signing is an owner, partner, member of firm, fiduciary, or a corporate officer.)

For Internal Revenue Service Use Only

Effective date granted

by IRS

For the Paperwork Reduction Act Notice, please see the back of this form,

Catalog Number 18770D

Form 2678 (Rev. 6-97)

2. Employer's or Payer's name

4. Employer identification number

5. Agent's name

7. Agent's employer identification number

□
□
□
□

□
□
□
□
□
□

Paperwork Reduction Act Notice

We ask for this information to carry out the Internal Revenue laws of the United States. We need it to ensure that taxpayers are complying with these laws and to allow us to figure and collect the right amount of tax. You are required to give us this information. The time needed to complete this form will vary depending on individual circumstances. The estimated average time is: 30 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form more simple, we would be happy to hear from you. You can write to the Tax Form Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. DO NOT send this form to this address. Instead, send it to the Director of the Internal Revenue Service Center where you file your returns.

File with the

Internal Revenue

Service Center at:

Holtsville, NY 00501

Andover, MA 05501

Philadelphia, PA 19255

Atlanta, GA 39901

Cincinnati, OH 45999

Austin, TX 73301

Ogden, UT 84201

Kansas City, MO 64999

Fresno, CA 93888

Memphis, TN 37501

Form 2678 (Rev. 6-97)