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Todd McIndoo is a Vice President at Speedy - National Association ...

Todd McIndoo is a Vice President at Speedy - National Association ...

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InstructionsProvide the following inform<strong>at</strong>ion for the Person/Business You Are Reporting if Known:1. Namea. Street Address of Residenceb. City, St<strong>at</strong>e, and Zip Codec. Social Security Numberd. D<strong>at</strong>e of the Person’s Birth2. Business Namea. Street Address of Businessb. City/St<strong>at</strong>e/Zip Codec. Enter Employer Identific<strong>at</strong>ion Numberd. Describe the Primary Business Activity3. Indic<strong>at</strong>e Martial St<strong>at</strong>usM - Married S - Single HH - Head of Household Div - Divorced Sep - Separ<strong>at</strong>ed3a. Enter name of spouse, if applicable.4. Check all Tax Viol<strong>at</strong>ions Th<strong>at</strong> Apply to Your Report or Describe in Comments If Not L<strong>is</strong>ted.5. If your report involves unreported income, indic<strong>at</strong>e the year(s) and the dollar amount(s)5a. Briefly describe the facts of the alleged viol<strong>at</strong>ion(s) as you know them. Please <strong>at</strong>tach another sheet, if you needmore room.5b. Indic<strong>at</strong>e (Yes or No) if books and/or records are available th<strong>at</strong> substanti<strong>at</strong>e your report.5c. Indic<strong>at</strong>e (Yes or No) if you consider the person to be violent or dangerous and provide an explan<strong>at</strong>ion in thecomments section of th<strong>is</strong> form.5d. L<strong>is</strong>t name and address of bank(s) and/or financial institution(s) used by the taxpayer if known.5e. Briefly explain how you learned of or obtained the inform<strong>at</strong>ion contained in your report. Please <strong>at</strong>tach anothersheet, if you need more room.6. Enter your name, street address, city, st<strong>at</strong>e, zip code and a telephone number where you can be contacted. Indic<strong>at</strong>etime of day you may be contacted if appropri<strong>at</strong>e. Th<strong>is</strong> Inform<strong>at</strong>ion <strong>is</strong> not Required to Process Your Report.Please print and send your completed form to the Internal Revenue Service <strong>at</strong>:Internal Revenue ServiceFresno, CA 93888PAPERWORK REDUCTION NOTICE: We ask for the inform<strong>at</strong>ion on th<strong>is</strong> form to carry out the Internal Revenue lawsof the United St<strong>at</strong>es. Th<strong>is</strong> report <strong>is</strong> voluntary and the inform<strong>at</strong>ion requested helps us determine if there has been aviol<strong>at</strong>ion of Income Tax Law. We need it to insure th<strong>at</strong> taxpayers are complying with these laws and to allow us tofigure and collect the right amount of tax.You are not required to provide the inform<strong>at</strong>ion on a form th<strong>at</strong> <strong>is</strong> subject to the Paperwork Reduction Act unless theform d<strong>is</strong>plays a valid OMB control number. Books or records rel<strong>at</strong>ing to a form or its instructions must be retained aslong as their contents may become m<strong>at</strong>erial in the admin<strong>is</strong>tr<strong>at</strong>ions of any Internal Revenue laws. Generally, tax returnsand tax return inform<strong>at</strong>ion are confidential, as required by Code section 6103.The time required to complete th<strong>is</strong> form will vary depending on individual circumstances. The estim<strong>at</strong>ed average time<strong>is</strong> 15 minutes.Privacy Act NoticeWe are requesting th<strong>is</strong> inform<strong>at</strong>ion under authority of 26 U.S.C. 7801.The primary purpose of th<strong>is</strong> form <strong>is</strong> to report potential viol<strong>at</strong>ions of the Internal Revenue laws.The inform<strong>at</strong>ion may be d<strong>is</strong>closed to the Department of Justice to enforce the tax laws.Providing the inform<strong>at</strong>ion <strong>is</strong> voluntary. Not providing all or part of the inform<strong>at</strong>ion will not affect you.C<strong>at</strong>alog Number 47872E Form 3949 A (Rev. 2-2007)28 — Exclusivefocus Winter 2009/2010

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