Notice 609 Privacy Act Notice Catalog Number 22710P Notice 784 Could You be Personally Liable for Certain Unpaid Federal Taxes www.irs.gov Form 4180 Rev. 8-2012 Page 2 Section IV - Business Information 1. Department of the Treasury - Internal Revenue Service Form 4180 Report of Interview with Individual Relative to Trust Fund Recovery August 2012 Penalty or Personal Liability for Excise Taxes Instructions The interviewer must prepare this form either in person or via telephone. Do not leave any information blank. Enter N/A if an item is not applicable. Section I - Person Interviewed 1. Name 2. Social Security Number SSN 3. Address street city state ZIP code 4. Home telephone number 5. Work telephone number 6. Name of Business and Employer Identification Number EIN 7. Did you use a third-party payer such as a payroll service Yes If yes complete Section VI A No 8. What was your job title and how were you associated with the business Describe your duties and responsibilities and dates of employment. If person being interviewed is a payroll service provider or a professional employer organization complete Section VI B Section II - Responsibilities 1. State whether you performed any of the duties / functions listed below for the business and the time periods during which you performed these duties. Dates Did you. Yes No From To a* Determine financial policy for the business b. Direct or authorize payments of bills/creditors c* Prepare review sign or authorize transmit payroll tax returns d. Have knowledge withheld taxes were not paid e. Authorize payroll f* Authorize or make Federal Tax Deposits g. Authorize the assignment of any EFTPS or electronic banking PINS/passwords h. Could other individuals do any of the above Complete Section IV and V Name Contact Number i. Have signature authority or PIN assignment on business bank accounts Bank Name s Account Number s Section III - Signatures I declare that I have examined the information given in this interview and to the best of my knowledge and belief it is true correct and complete. Signature of person interviewed Signature of Interviewer Date copy of completed interview form given to person interviewed Taxpayer Statement on Page 4 Yes Interview Continued on subsequent pages Interview Handouts X if given or explain why not in case history. List corporate positions below identifying the persons who occupied them and their dates of service. Position e*g* president director Address 2. Did/does the business use the Electronic Federal Tax Payment System EFTPS to make Federal Tax Deposits FTD s or payments 3. Other than the EFTPS does the business do any other banking electronically If yes to whom are the PINS or passwords assigned Where To whom are the PINs/passwords assigned 4. Does the business file Form 941 electronically Who is authorized to sign Form 941 Who files the returns electronically Section V - Knowledge / Willfulness 1. During the time the delinquent taxes were increasing or at any time thereafter were any financial obligations of the business paid such as rent mortgage utilities vehicle or equipment loans or payments to vendors Which obligations were paid 2.
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