pdf2json/test/data/fd/form/F4868.content.txt

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rejected. If you don't have a prior year Adjusted Gross Income you can obtain an 
Amount you are paying (see instructions)
Checking         Savings         N/A (no direct debit)
Form
 
4868
Application for Automatic Extension of Time
OMB NO. 1545-0074
Department of the Treasury
to File U.S. Individual Income Tax Return
2013
Internal Revenue Service (99)
For calendar year 2013, or other tax year beginning
,2013 ending
, 20
.
Part I
Identification
Part II
Individual Income Tax
1
Your name(s) (see instructions)
4
Estimate of total tax liability for 2013
. . . . . . . . . . 
$
5
Total 2013 payments
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Address (see instructions)
6     Balance due.  
Subtract line 5 from line 4
(see instructions)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
City, town or post office
State       ZIP Code
7
. . . . . 
G
8
Check here if you are "out of the country" and a U.S.
Foreign country name
Province    Postal Code           citizen or resident (see instructions)
. . . . . . . . . . . . . . . . . 
G
9
Check here if you file Form 1040NR or 1040NR-EZ and
2
Your social security number
3
Spouse's social security number
did not receive wages as an employee subject to U.S.
income tax withholding
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
G
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Cat. No. 13141W
Form
 
4868
 (2013)
Information for Paper Filing of Extension           Required Information for Electronic Filing of Extension
Paying Tax Due by Check
. . . . . . . . . . . . . . 
. . . . . . . . . . . . . . . . 
in the instructions.
Disclosure Statement
I agree
I consent to allow my Intermediate Service Provider, transmitter, or Electronic Return Originator (ERO) to 
send this form to the IRS and to receive the following information from the IRS: (a) Acknowledgement of 
receipt or reason for rejection of transmission , and (b) if delayed, reason for any delay in processing the 
form.
Paying Tax Due by Check
  
Print Form 4868 and attach check for balance due. Mail to the address in the instructions
Electronic Withdrawal of Tax Due
To use direct debit, enter the required information below and agree to the disclosure statement.
G
Routing number
. . . . . . . . . . . 
G
Account number
. . . . . . . . . . . 
G
Type:
. . . . . . . . . . . . . . . . . . . . . . 
Date to make withdrawal
. . . . . . . . . . . . 
G
Day time phone number
. . . . . . . . . . . . . . . . . . . . . 
IMPORTANT: Identifying Information From Last Year (2012 taxes)
The IRS uses this information to verify your identity. They will match this information against what 
they have in their records, so don't guess.  If the information does not match, your return will be 
Electronic Filing PIN from the IRS web site. Go to
http://www.irs.gov/Individuals/Electronic-Filing-PIN-Request
 or call 1-866-704-7388. 
Enter the Electronic Filing PIN  in the space indicated "Electronic Filing PIN".
Note:
If you are married filing joint, and you filed together in 2012, enter the same 
amount in the taxpayer and spouse columns for adjusted gross income.
Taxpayer
Spouse
(1) Prior Year Adjusted Gross Income:
. . . . . . . . 
OR
(2) Electronic Filing PIN:
. . . . . . . . . . . . . . . . . . . . . . . 
- Print Form 4868 and
attach check for balance due. Mail to the address 
Re-enter e-mail address (must match)
       
E-Mail address (for confirmation e-mail
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(Your PIN(s) cannot be 12345 or 00000)
. . . . . . 
Date of Birth (mm/dd/yyyy)
. . . . . . . . . . . . . . . . . . . . 
Today's Date (mm/dd/yyyy)
. . . . . . . . . . . . . . . . . . . . 
Electronic withdrawal disclosure statement
I agree
I authorize the U.S. Treasury and its designated Financial Agent to intitiate an ACH Electronic Funds 
Withdrawal (Direct Debit) entry to the financial institution account indicated for payment of my federal taxes 
owed on this return and the financial institution to debit the entry to this account.  This authorization is to 
remain in full force and effect until I notify the U.S. Treasure Financial Agent to terminate the authorization. 
To revoke a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 
business days prior to the payment (settlement) date.  I also authorize the financial institutions involved in the
processing of the electronic payment of taxes to receive confidential information necessary to answer 
inquiries and resolve issues related to the payment.
Signature information
Taxpayer
Spouse
Select any 5-digit PIN
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