Form 9041 – Fill Out and Use This PDF

Form9041

(Rev. September 1999)

Department of the Treasury

Internal Revenue Service

Application for Electronic/Magnetic Media Filing of

Business and Employee Benefit Plan Returns

OBM No. 1545-1079

c Mailing Address (Street, P.O. Box, City, State, Zip Code)

d Contact person's name

Daytime telephone number

(Include area code.)	( ___ )	____________________
FAX telephone number
(Include area code.)	( ___ )	____________________

2Indicate which forms you will file by checking each appropriate box.

Form 5500, Annual Return/Report of Employee Benefit Plan (with 100 or more Participants)

Form 5500-C/R, Return/Report of Employee Benefit Plan (with fewer than 100 Participants)

Form 5500-EZ, Annual Return of One-Participant (Owners and Their Spouses) Retirement Plan

Form 1041, U.S. Income Tax Return for Estates and Trusts

Form 1065, U.S. Partnership Return of Income (See back of this form for instructions)

Form

Form

4Please answer the following questions by checking the appropriate box(es):

a Will you send return data directly to IRS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b Will you develop or modify software that prepares returns for electronic/magnetic media filing? . . .

c Will you file using Magnetic tape?		Floppy Diskette (3 1/2" or 5 1/4")?		Modem?

Yes No

Yes No

Applicant Agreement

Under the penalties of perjury, I declare that I have examined this application and any accompanying information, and to the best of my knowledge and belief it is true, correct and complete. This firm and its employees will comply with all the provisions of the procedures for electronic/magnetic media filing of Forms 1041, 1065, 5500, 5500-C/R, or 5500-EZ as applicable. The firm understands that if it is sold or its organizational structure is changed, acceptance for participation is not transferable; a new application must be filed. The firm further understands that noncompliance will result in the firm no longer being allowed to participate in the program. I am authorized to make and sign this statement on behalf of the firm.

7Signature of person responsible for this application

Date

Privacy Act Notice.–The Privacy Act of 1974 requires that when we ask you for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it and whether your response is voluntary, required to obtain a benefit, or mandatory.

Our legal right to ask for the information is Internal Revenue Code sections 6001, 6011, and 6012(a) and their regulations. We are asking for this information to verify your status as a person qualified to participate in the electronic filing program. Your response is voluntary. Failure to provide the requested information could result in your disqualification from the electronic filing program. If you provide fraudulent information, you may be subject to criminal prosecution.

Paperwork Reduction Act Notice.—We ask for the information on this form to carry out the Internal Revenue laws of the United States. You must give us the information if you wish to participate in the electronic/magnetic media filing program. We need it to process your application to file Business and Employee Benefit Plan Returns on electronic/magnetic media.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The time needed to complete this form will vary depending upon individual circumstances. The estimated average time is 18 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Tax Forms Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. DO NOT

send this application to this office. Instead, see instructions below for where to file.

General Instructions

Who must file.—File Form 9041 if you would like to

take part in the electronic/magnetic media filing program for Forms 1041, 1065, 5500, 5500-C/R, and 5500-EZ. Only those who did not participate in last year’s electronic/magnetic media filing program need apply, and those for whom information in item 1 has changed since we last contacted you. EXCEPTION:

To take part in the Form 1065 electronic filing program, current and new participants must file Form 9041.

When to file. To ensure complete and timely review of your application, file Form 9041 at least 60 calendar days before you file electronically. IRS uses the postmark date on the envelope to determine whether the application was filed timely.

Where to file. Send the completed Form 9041 for Forms

1041 to:

Internal Revenue Service Philadelphia Service Center ATT: DP 115

11601 Roosevelt Blvd.

Philadelphia, PA 19154 Phone: 215-516-7533

Send the completed Form 9041 for Forms 1065 to: Internal Revenue Service

Austin Service Center

Attn: EFU, Stop 6380 P.O. Box 1231 Austin, TX 78767 Phone: 512-460-8900

Send the completed Form 9041 for Forms 5500, 5500-C/R and 5500-EZ to:

Internal Revenue Service Attn: EFU (EPMF), Stop 261 P.O. Box 30309, A.M.F. Memphis, TN 38130

Phone: 901-546-2690, ext. 7516

Line By Line Instructions

Line 1a.―Enter the name as shown on your tax return.

Line 1c.―If you have both a post office box and street address, enter both addresses for the firm’s main office. We need both addresses in case we need to send information to you by overnight mail.

Line 1d.―If this information changes, please notify the IRS Service Center where you originally filed Form 9041. We need this information in case questions arise and to fax revised documentation or the Acknowledgement Report if it is six pages or less.

Line 2.―If you want to electronically file a form that isn’t listed and you know we’ve added it to our electronic filing program since this form’s revision date (lower right corner), please enter it on one of the blank lines labeled Form. See Publication 1524, procedures for more information about filing Form 1065 electronically.

Line 5.―If this information changes, please notify the appropriate service center. If you will use your own software or communication equipment, please indicate this in the space provided. Please include the name, address, phone number, and contact person’s name, if applicable.