Form 4810 (Rev. 2-2009)

1 OMB No. 1545-0430 request for Prompt assessment UnderInternal revenue Code Section 6501(d) Department of the TreasuryInternal revenue Service form 4810 (Rev. 2- 2009 ) Cat. No. 42022S Spouse s social security number form See instructions on back. 4810 Requester s name Income Employment Gift Kind of tax Excise Tax Returns for Which Prompt assessment of Any Additional Tax is Requested If applicable, provide the name of decedent s spouse (surviving or deceased) Dissolution has been completed. I request a prompt assessment of any additional tax for the kind of tax and periods shown above, as provided by internal revenue Codesection 6501(d). If corporate income tax returns are included, check the applicable box below: For Privacy Act and Paperwork Reduction Act Notice, see back of form . (Rev. February 2009 ) For IRS Use Only Title Number, street, and room or suite no.

2 (If a box, see instructions.) City, town, or post office, state, and ZIP code Daytime phone number FormNumber Tax PeriodEnded SSN/EIN onReturn Name and Address Shown on Return Service Center Where Filed Date Filed Dissolution has not begun but will begin before the 18-month period of limitation expires and will be completed either before or afterthat period expires. Dissolution has begun and will be completed either before or after the 18-month period of limitation. The returns listed above. Attached are copies of: Other (describe): Letters of administration or letters testamentary. Under penalties of perjury, I declare that I have examined this request , including accompanying schedules and statements, and to the best of myknowledge and belief, it is true, correct, and complete. Identifying number Date Signature of requester Sign Here I certify that I have never been assessed any penalties for civil fraud for any federal or state tax matter nor have I been charged with,indicted for, or convicted of fraud.

3 If you cannot certify this statement, attach a detailed statement explaining the circumstances underwhich you were assessed a penalty, charged with, indicted for, or convicted of fraud. form 4810 (Rev. 2- 2009 ) Page 2 The date and location of the IRS office where thereturns were filed. When To File Do not file form 4810 requesting prompt assessmentuntil after you file the tax returns listed on the front ofthis form . You must submit a separate request forprompt assessment for any tax returns filed after thisForm 4810. The name and social security number (SSN) oremployer identification number (EIN) shown on thereturn (copies of the returns may be attached to helpidentify the return; write at the top of the return copy: COPY - DO NOT PROCESS AS ORIGINAL ); and General Instructions Purpose of form Section references are to the internal revenue Code.

4 Use form 4810 to request prompt assessment of to your request the documentation requestedon form 4810. If you prefer to use your own format,your request must list the same information asrequested on this form and include the applicableattachments. Specifically, you must verify yourauthority to act for the taxpayers (for example, letterstestamentary or letters of administration) and providecopies of the authorizing document. Also, your requestmust clearly show: It is a request for prompt assessment under section6501(d); The kind of tax and the tax periods involved; Where To File Send your request to the internal revenue ServiceCenter where you filed the returns for which you arerequesting prompt assessment . not required to request prompt assessment ; however,if you do so you are required to provide theinformation requested on this form .

5 Failure to providethe information may delay or prevent processing yourrequest. Section 6109 requires you to provide therequested taxpayer identification numbers. Recordkeeping 5 hrs., 30 min. Learning about the law or the form0 hrs., 18 min. Preparing the form 0 hrs., 24 min. If you have comments concerning the accuracy ofthese time estimates or suggestions for making thisrequest simpler, we would be happy to hear from can write to the internal revenue Service, TaxProducts Coordinating Committee,SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW,IR-6526, Washington, DC 20224. Do not send this taxform to the above address. Instead, see Where To Fileon this page. You are not required to provide the informationrequested on a form that is subject to the PaperworkReduction Act unless the form displays a valid OMBcontrol number. Books or records relating to a form orits instructions must be retained as long as theircontents may become material in the administration ofany internal revenue law.

6 Generally, tax returns andreturn information are confidential as required bysection 6103. However, section 6103 allows or requiresthe internal revenue Service to disclose or give suchinformation shown on your form 4810 to theDepartment of Justice to enforce the tax laws, bothcivil and criminal, and to cities, states, the District ofColumbia, and commonwealths or may also disclose this information to othercountries under a tax treaty, to federal and stateagencies to enforce federal nontax criminal laws, or tofederal law enforcement and intelligence agencies tocombat terrorism. Copying, assembling, andsending the form to the IRS0 hrs., 0 min. Privacy Act and Paperwork Reduction Act ask for the information on this form to carry out theInternal revenue laws of the United States. We collectthis information under the authority under InternalRevenue Code section 6501(d).

7 We need it to ensurethat you are complying with these laws and to allow usto figure and collect the right amount of tax. You are The time needed to complete and file this form andrelated schedules will vary depending on individualcircumstances. The estimated average times are.