Complete this form, notarize, and send it to us by scanning the QR code and using the Document Upload Tool
(DUT). Include a copy of valid photo identification. Refer to your notice CP322 or CP322B for information on the
DUT. You can also mail this form and copy of valid form of photo identification to us at the address provided in
your notice.
Practice Information
Name CAF number
Business name
Business address (number, street, apt/room/suite number)
Person Submitting this Form
Notary Acknowledgment
State of County of
I, a duly appointed and commissioned Notary Public (notary name)
Certify that on this day (dd/mm/yy)
Personally appeared before me (signer’s name)
Known to be the individual whose name is subscribed to the document and presented to me a document titled
Seal
Catalog Number 96407B www.irs.gov Form 15122 (6-2026)
