0117 Form 10301 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f10301.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(January 2017)

Department of the Treasury - Internal Revenue Service

Type or print in black ink.

1. Type of request*

Original Revised

2. Payer information (company receiving CD)

Legal name*

Address* (street) City* State* ZIP code*

3. Taxpayer Identification Number (TIN)* (9 digit EIN or SSN)

EIN - OR SSN - 4. Primary Company contact

Name* Telephone number*

5. Secondary Company contact

Name* Telephone number*

6. Personal Identification Number (PIN)* (provide a self-assigned alphanumeric 10-digit PIN)

7. I have read the Affidavit in the Instructions on page 2 and I am authorized to sign the document on behalf of the payer*

Affidavit

Under penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct and complete, and I have the authority to execute this form. The contact person(s) listed above is authorized to receive encryption code(s) for CP2100/972CG Notices.

8. Official of the Company or Organization

Name* (type or print) Signature*

Title* Date*

All fields marked with an asterisk () are required fields.

Catalog Number 33392H www.irs.gov Form 10301 (Rev. 1-2017)

Page 2

Instructions for Form 10301, CD Encryption Code Authorization For CP2100/972CG Notices

General Instructions Use Form 10301 to authorize a contact person to receive an encryption code required to read a compact disk (CD) containing:

• Notice CP2100, Please check your Backup Withholding List

• Notice 972CG, A Penalty is proposed for your Information Returns

Revise Form 10301 Information - Check the box located at the top of the form and complete form with current company information.

Timeframe - Allow 5 business days from the date IRS receives this form.

Specific Instructions Complete this form with black ink.

All fields marked with an asterisk (*) are required fields.

Block 1 - Check the box for Original or Revised.

Block 2 - Enter the legal name and complete street address of the company (payer) receiving the CD containing CP2100/ 972CG Notices.

Block 3 - Enter the nine-digit Taxpayer Identification Number (TIN) [Employer Identification Number (EIN) or the Social Security Number (SSN)] of the payer.

Block 4 - Enter the name and telephone number of the primary contact person authorized to receive the encryption code. It is the responsibility of the contact person to know company's PIN.

Block 5 - Enter the name and telephone number of the secondary contact person authorized to receive the encryption code. It is the responsibility the contact person to know company's PIN.

Block 6 - Enter a self-assigned ten digit PIN. The PIN must be ten alphanumeric characters. Special characters are not allowed. This PIN is used to authorize the contact to receive the encryption code. Retain the PIN for future reference. The encryption code will not be provided prior to PIN verification.

Block 7 - Affidavit. This application must be completed and submitted by: (a) the owner, if the applicant is a sole proprietorship, (b) the president, vice president, or other principal officer, if the applicant is a corporation, (c) a responsible and duly authorized member or officer having knowledge of its affairs, if the applicant is a partnership, government entity, or other unincorporated organization, or (d) the fiduciary, if the applicant is a trust or an estate. Check the box to confirm that you have read the affidavit and are authorized to sign on behalf of the company.

Block 8 - Form 10301 must be signed and dated by an official of the company or organization. If you have a power of attorney, attach a copy to this form.

Note: This Form 10301 automatically revokes all prior authorizations.

Where to file

Internal Revenue Service 230 Murall Drive, Mail Stop 4360 Kearneysville, WV 25430

Fax: (877) 477-0572 (within the U.S) (304) 579-4105 (International)

Please either fax or mail, do not do both.

Upon receipt of the CD, the primary or secondary contact is required to call the IRS to receive the encryption code. Assistance is available Monday through Friday at:

• (866) 455-7438 (Toll Free)

• (304) 263-8700 (International)

Paperwork Reduction Act Notice

We ask for the information on these forms to carry out the Internal Revenue Laws of the United States. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103. The time needed to provide this information would vary depending on individual circumstances. The estimated average time is: Preparing Form 10301 is 15 minutes.

If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we would be happy to hear from you. Write to the Tax Forms Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. Do not send Form 10301 to this address.

Catalog Number 33392H www.irs.gov Form 10301 (Rev. 1-2017)