REPORTING AGENT'S LIST DATE OF LIST Reporting Agent's Name Reporting Agent’s Street Address Reporting Agent’s City, State, ZIP Reporting Agent’s Employer Identification Number List Type (Additions or Deletions) Name of Reporting Agent’s Contact Person Phone Number of Reporting Agent’s Contact Person Client Account Number (optional) Employer Identification Number* Name Control (IRS Supplied) Taxpayer Name and Address * Employer Identification Numbers must be listed in ascending numerical order. NOTE: Only one copy of the Reporting Agent’s List should be submitted, along with the Forms 8655, to: Internal Revenue Service Accounts Management Service Center MS 6748; RAF Team 1973 N. Rulon White Blvd. Ogden, UT 84404 or fax Forms 8655 and paper Reporting Agent Lists to the RAF Team at (801) 620-4142.

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