USA TAX REGISTRATION

SPANISH VERSION

REALIZAR SU DECLARACIN DE IMPUESTOS DE EE.UU. CON TAXBACK.COM ES RPIDO

Y SENCILLO, SOLO SIGA LOS SIGUIENTES PASOS:

Imprima y complete los formularios

utilizando la lista de verificacin a
continuacin para ayudarlo

Escane todos los formularios y los

documentos adicionales requeridos*

Enve por email las copias escaneadas

a usdocuments@taxback.com

*Asegrese de establecer el tamao de papel en A4 y la resolucin a un mnimo de 300dpi. Guarde el archivo en formato PDF, JPG o JPEG antes de envirnoslos por email. Cada
archivo no debe exceder los 2MB. Si tiene dificultades escaneando sus documentos, por favor, comunquese con nosotros en www.taxback.com/chat o llame a la oficina ms
cercana en www.taxback.com/contactus.asp.

Gracias por elegir taxback.com. Estamos ansiosos de trabajar con usted para presentar su declaracin de impuestos. En este pack,
encontrar todo lo que necesita para autorizar a taxback.com a declarar impuestos en su nombre. En Taxback.com, sabemos que no
todos los asuntos fiscales son iguales. Es por este motivo, que hay mucha informacin en el presente pack. Sin embargo, solo necesita
completar las secciones que le corresponden. Si necesita ayuda con el formulario, djenoslo saber y haremos que alguien se comunique
con usted y le explique.

LISTA DE VERIFICACIN
Por favor, tenga en cuenta que necesitamos que el pack est completo, antes de que podamos confirmarle su situacin fiscal en EE.UU.
Hemos preparado la presente lista de verificacin a continuacin, para que pueda asegurarse de completar todas las secciones y de que cuenta
con toda la documentacin requerida.

1.

Formulario de aplicacin
Por favor, complete ambas pginas en
su totalidad. Entre ms informacin
brinde, ms rpido podremos procesar
su solicitud.

3.

Formularios 8821 y 8822

Por favour firme y feche donde se
encuentra indicado con el .

5.

6.

Formulario 7216
Por favor escriba su nombre, firme y
feche el formulario donde se encuentra
indicado con el .
ID
Envenos una fotocopia de su visa
de EE.UU. (o la pgina de ID de su
pasaporte) y una copia de su tarjeta
de social security.

2.

Formulario 2848
Por favor firme y feche el formulario en la segunda
pgina donde se encuentra indicado con un .
Nota: Si est casado, cada cnyuge debe firmar y
fechar una copia por separado del formulario 2848.

4.

Acuerdo del cliente y formulario de poder legal

Por favor, firme y feche donde se encuentra
indicado con un .

7.

Sus documentos de pago

Envenos los ltimos documentos de pago de
cada empleador formularios W2, ltimas boletas
de pago o cualquier otra declaracin de ingresos
acumulada que demuestre ingresos de fuentes
estadounidenses e impuestos pagados en EE.UU.
(tales como los formularios 1099, 1042S, etc.).

taxback.com, 333 N. Michigan Avenue, Suite 2415, Chicago, IL, 60601

1
www.taxback.com

USA TAX REGISTRATION

SPANISH VERSION

FORMULARIO DE APLICACIN / APPLICATION FORM

INFORMACIN DE CONTACTO POR FAVOR, ESCRIBA EN MAYSCULAS / CONTACT INFORMATION PLEASE PRINT IN BLOCK CAPITALS
Ttulo:
Title:

Sr.

Sra.

Mr

Mrs

Nombres

Stra.

Fecha de Nacimiento dd / mm / yy
Date of Birth

Email

Apellidos

Katia

First Name

Miss

Celular
Mobile

24/11/89

Surname

Condori Mamani

Telfono

+51 9598598559

Telephone

katia.condori@ucsp.edu.pe

Email

Direccin Postal

04000

Postal Address

Nacionalidad

Cmo se enter de nuestros servicios?

Peruana

Nationality

Internet

How did you hear about our services?

INFORMACIN DE LA VISA / VISA INFORMATION

Tipo de visa:
Visa Type:

Turista
Tourist

J1

F1

Otros

Other

H1B

H2B

(por favor, especifique)

______________________________________
(please specify)

18/12/13

Otros
Other

Work & Travel

Intern

(por favor, especifique)

(please specify) _________________________________

Date of departure from the USA

Ha presentado una declaracin de impuestos de EE.UU. con el IRS antes? Yes

No

Have you ever filed a US tax return with the IRS before?

No

Yes

Para qu ao fiscal est aplicando actualmente?

Which tax year are you applying for now?

Program Type:

Fecha de salida de EE.UU. dd / mm / yy

Fecha de llegada a EE.UU. dd / mm / yy

Date of arrival in the USA

Tipo de Programa:

2013

_____________________

08/03/14

De ser as, por favor coloque el ao:

If yes, please state for which year: _______________________________

Ha aplicado para el presente ao fiscal anteriormente?

Have you applied for this tax year before?

No

Yes

No

Si estuvo en EE.UU. antes del ao fiscal al que est aplicando, es importante que brinde informacin acerca de aquellas visitas incluyendo el tipo de
visa y los das que estuvo en EE.UU. por favor, complete la informacin en el siguiente cuadro:
If you were in the US before the tax year you are applying for, it is important to provide information about those visits including visa type and days of
presence in the US - please complete the information in the grid below:

2013

2012

2011

2010

2009

Tipo de Visa / Visa Type

(vea la lista que aparece anteriormente
para las opciones) / (see list above for
options)
Nmero de das que pas en EE.UU.
Number of days spent in the US

INFORMACIN DE LA RESIDENCIA / RESIDENCY INFORMATION

Tuvo algn trabajo en su pas de origen?
Antes de que estuviera en EE.UU.
Before you were in the US

Did you have a job in your home country?

En qu pas pas la mayor parte de su tiempo?

Which country did you spend most of your time in?

Yes

Despus de haber estado en EE.UU.

After you were in the US

Tuvo la intencin de regresar a su pas de origen?

Per

No

No

No

No

Yes

Did you intend to return to your home country?

Yes

Tuvo una cuenta bancaria en su pas de origen?

Did you have a bank account in your home country?

Yes

Regres a la Universidad?
Did you return to University?

taxback.com, 333 N. Michigan Avenue, Suite 2415, Chicago, IL, 60601

No

____________________________________

Su correo llegaba a su domicilio?

Did your mail go to your home address?
Mientras estuvo en EE.UU.
While you were in the US

No

Yes

No

No

No

No

www.taxback.com

USA TAX REGISTRATION

SPANISH VERSION

Por favor, marque los gastos diarios por los que pag en su pas de origen, mientras estuvo en su programa en EE.UU.:
Please tick which living expenses you paid for in your home country, while you were on your US program:
Seguro (Mdico/ Casa/ Salud, etc.)
Insurance (Medical / Home / Health etc)

Club Membership (Gym / Sports / Social etc)

Gastos de celular

Tarifas de Seguro/Registro para vehculos de transporte (Auto/Motocicleta/Bicicleta)

Mobile Phone Costs

Membresa del Club (Gimnasio, Deportes, Social, etc.)

Insurance / Registration fees for transportation vehicles (Car / Motorbike / Bicycle)

Otros

Gastos de vivienda (Alquiler/Hipoteca)

Housing Costs (Rent / Mortgage)

Other

(por favor, especifique)

(please specify) _______________________________________________________

GASTOS DEL PROGRAMA EN EE.UU. / YOUR US PROGRAM EXPENSES

Gastos
Costs

Moneda
Currency

Programa (Work & Travel, Internship, etc)

Program (Work & Travel, Internship, etc.)

Vuelos (a /desde EE.UU.)

Monto
Amount

Dlares

3500

Dlares

2000

Flights (to and from the US)

Ao pagado
Year Paid

2013

No

No

No

No

No

No

Yes

2013

Yes

Alquiler (alquiler total pagado en EE.UU.)

Rent (total rent paid in the US)

Dlares

2013-2014

1200

Si respondi No, puede

probarlo?
If No, can you obtain proof?

Recibo S/No*
Receipt Yes/No*

Yes

No

Yes

No

Yes

No

Yes

No

No

No

*Si usted tiene recibos por favor incluya una copia de los mismos cuando nos devuelva este pack. Si no tiene recibos, tenga en cuenta que se requieren para que los gastos
anteriores se puedan utilizar en el clculo - su ejecutivo de cuenta le aconsejar si necesitamos que obtenga copias en ese momento.
*If you have receipts please include a copy of the receipts when you return this pack to us. If you do not have receipts, please note receipts are required if the above expenses
can be used in your calculation your account manager will advise you if we need you to obtain copies at that time.

INFORMACIN DEL EMPLEO / EMPLOYMENT INFORMATION

EMPLEADOR 1 / EMPLOYER 1
Nombre de la compaa / Company name
Direccin / Address
Telfono / Telephone

Kllington Market INC

2023 Killington Road

Vermont

Estado en el que trabaj / State you worked in

054 - 41 - 0237

09/03/13
Fecha en la que comenz a trabajar / Start work date dd / mm / yy

ltimo da de trabajo / Final work date

Su empleador cubri los gastos por su: / Did your employer cover the cost of your: Comida/Food S/Yes
Tiene su formulario W2? / Do you have your W2 Form? S/ Yes

No / No

No/No

06/03/14
dd / mm / yy

Alojamiento/Accommodation S/Yes

No/No

Si contest no, le gustara que obtengamos un duplicado para usted?* S

If no, would you like us to get a replacement for you?*

No

Yes

No

EMPLEADOR 2 / EMPLOYER 2
Nombre de la compaa / Company name
Direccin / Address
Estado en el que trabaj / State you worked in

Telfono / Telephone
Fecha en la que comenz a trabajar / Start work date

dd / mm / yy

ltimo da de trabajo / Final work date

Su empleador cubri los gastos por su:/Did your employer cover the cost of your: Comida/Food S/Yes
Tiene su formulario W2? / Do you have your W2 Form? S/ Yes

No / No

No/No

dd / mm / yy

Alojamiento/Accommodation S/Yes

No/No

Si contest no, le gustara que obtengamos un duplicado para usted?* S

If no, would you like us to get a replacement for you?*

Yes

No
No

Si tuvo ms de dos empleadores o algn otro ingreso adicional en EE.UU., por favor, incluya la informacin en una hoja separada.
If you had more than 2 employers or any additional income from the US please include information on a separate page.
*Se aplicar una tarifa por Recuperacin de Documentos / *Document retrieval fee applies

taxback.com, 333 N. Michigan Avenue, Suite 2415, Chicago, IL, 60601

www.taxback.com

Form

2848

(Rev. July 2014)

Department of the Treasury
Internal Revenue Service

Part I

OMB No. 1545-0150

Power of Attorney
and Declaration of Representative
a

For IRS Use Only

Received by:

Information about Form 2848 and its instructions is at www.irs.gov/form2848.

Name

Power of Attorney

Telephone

Caution: A separate Form 2848 must be completed for each taxpayer. Form 2848 will not be honored
for any purpose other than representation before the IRS.

Function
Date

Taxpayer information. Taxpayer must sign and date this form on page 2, line 7.

Taxpayer name and address

Taxpayer identification number(s)

Daytime telephone number

Plan number (if applicable)

hereby appoints the following representative(s) as attorney(s)-in-fact:

2

Representative(s) must sign and date this form on page 2, Part II.

Name and address

ILIYAN TZAKOV
TAXBACK
14 ST STEPHEN'S GREEN, DUBLIN 2, IRELAND
Check if to be sent copies of notices and communications

CAF No.
PTIN
Telephone No.
Fax No.
Check if new: Address

0304-87184R
P00745795
+353 1 635 3740
+353 1 670 6963
Telephone No.

Fax No.

Telephone No.

Fax No.

Telephone No.

Fax No.

CAF No.

Name and address

Check if to be sent copies of notices and communications

PTIN
Telephone No.
Fax No.
Check if new: Address
CAF No.
PTIN

Name and address

Telephone No.
(Note. IRS sends notices and communications to only two representatives.)

Fax No.
Check if new: Address
CAF No.
PTIN

Name and address

Telephone No.
Fax No.
Check if new: Address
Fax No.
Telephone No.
(Note. IRS sends notices and communications to only two representatives.)
to represent the taxpayer before the Internal Revenue Service and perform the following acts:
3
Acts authorized (you are required to complete this line 3). With the exception of the acts described in line 5b, I authorize my representative(s) to receive and
inspect my confidential tax information and to perform acts that I can perform with respect to the tax matters described below. For example, my representative(s)
shall have the authority to sign any agreements, consents, or similar documents (see instructions for line 5a for authorizing a representative to sign a return).
Description of Matter (Income, Employment, Payroll, Excise, Estate, Gift, Whistleblower,
Practitioner Discipline, PLR, FOIA, Civil Penalty, Sec. 5000A Shared Responsibility
Payment, Sec. 4980H Shared Responsibility Payment, etc.) (see instructions)

Tax Form Number

(1040, 941, 720, etc.) (if applicable)

INDIVIDUAL INCOME TAX

FICA TAX
ITIN
4
5a

Year(s) or Period(s) (if applicable)

(see instructions)

1040, 1040NR

2014, 2013, 2012, 2011

843, 8316

2014, 2013, 2012, 2011

W-7
Specific use not recorded on Centralized Authorization File (CAF). If the power of attorney is for a specific use not recorded on CAF,
a
check this box. See the instructions for Line 4. Specific Use Not Recorded on CAF . . . . . . . . . . . . . . .
Additional acts authorized. In addition to the acts listed on line 3 above, I authorize my representative(s) to perform the following acts (see
instructions for line 5a for more information):

Authorize disclosure to third parties;

Other acts authorized: RECEIPT OF REFUND CHECKS AS AGENT FOR TAXPAYER

Substitute or add representative(s);

Sign a return; THIS POWER OF ATTORNEY IS

BEING FILED PURSUANT TO REGULATIONS SECTION 1.6012-1(a)(5) BY REASON OF CONTINUOUS ABSENCE FROM THE USA A S
APPLICABLE TO US RESIDENTS AND SECTION 1.6012-1(b)(3) AS APPLICABLE TO NON-RESIDENTS

For Privacy Act and Paperwork Reduction Act Notice, see the instructions.

Cat. No. 11980J

Form 2848 (Rev. 7-2014)

Page 2

Form 2848 (Rev. 7-2014)

Specific acts not authorized. My representative(s) is (are) not authorized to endorse or otherwise negotiate any check (including directing or
accepting payment by any means, electronic or otherwise, into an account owned or controlled by the representative(s) or any firm or other
entity with whom the representative(s) is (are) associated) issued by the government in respect of a federal tax liability.
List any specific deletions to the acts otherwise authorized in this power of attorney (see instructions for line 5b):

Retention/revocation of prior power(s) of attorney. The filing of this power of attorney automatically revokes all earlier power(s) of
attorney on file with the Internal Revenue Service for the same matters and years or periods covered by this document. If you do not want
to revoke a prior power of attorney, check here . . . . . . . . . . . . . . . . . . . . . . . . . . a

YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.
Signature of taxpayer. If a tax matter concerns a year in which a joint return was filed, each spouse must file a separate power of attorney
even if they are appointing the same representative(s). If signed by a corporate officer, partner, guardian, tax matters partner, executor,
receiver, administrator, or trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.

IF NOT COMPLETED, SIGNED, AND DATED, THE IRS WILL RETURN THIS POWER OF ATTORNEY TO THE TAXPAYER.
Miss

02/26/15
mm/dd/yy
Signature

Date

Print Name

Part II

Title (if applicable)

Print name of taxpayer from line 1 if other than individual

Declaration of Representative

Under penalties of perjury, by my signature below I declare that:

I am not currently suspended or disbarred from practice before the Internal Revenue Service;
I am subject to regulations contained in Circular 230 (31 CFR, Subtitle A, Part 10), as amended, governing practice before the Internal Revenue Service;
I am authorized to represent the taxpayer identified in Part I for the matter(s) specified there; and
I am one of the following:
a Attorneya member in good standing of the bar of the highest court of the jurisdiction shown below.
b
c
d
e
f

Certified Public Accountantduly qualified to practice as a certified public accountant in the jurisdiction shown below.
Enrolled Agentenrolled as an agent by the Internal Revenue Service per the requirements of Circular 230.
Officera bona fide officer of the taxpayer organization.
Full-Time Employeea full-time employee of the taxpayer.
Family Membera member of the taxpayers immediate family (for example, spouse, parent, child, grandparent, grandchild, step-parent, stepchild, brother, or sister).
g Enrolled Actuaryenrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the authority to practice before
the Internal Revenue Service is limited by section 10.3(d) of Circular 230).
h Unenrolled Return PreparerYour authority to practice before the Internal Revenue Service is limited. You must have been eligible to sign the
return under examination and have prepared and signed the return. See Notice 2011-6 and Special rules for registered tax return preparers
and unenrolled return preparers in the instructions (PTIN required for designation h).
i Registered Tax Return Preparerregistered as a tax return preparer under the requirements of section 10.4 of Circular 230. Your authority to
practice before the Internal Revenue Service is limited. You must have been eligible to sign the return under examination and have prepared and
signed the return. See Notice 2011-6 and Special rules for registered tax return preparers and unenrolled return preparers in the
instructions (PTIN required for designation i).
k Student Attorney or CPAreceives permission to represent taxpayers before the IRS by virtue of his/her status as a law, business, or accounting
student working in an LITC or STCP. See instructions for Part II for additional information and requirements.
r Enrolled Retirement Plan Agentenrolled as a retirement plan agent under the requirements of Circular 230 (the authority to practice before the
Internal Revenue Service is limited by section 10.3(e)).
a

IF THIS DECLARATION OF REPRESENTATIVE IS NOT COMPLETED, SIGNED, AND DATED, THE IRS WILL RETURN THE
POWER OF ATTORNEY. REPRESENTATIVES MUST SIGN IN THE ORDER LISTED IN PART I, LINE 2. See the instructions for
Part II.
Note. For designations d-f, enter your title, position, or relationship to the taxpayer in the "Licensing jurisdiction" column. See the instructions for Part II
for more information.
Designation
Insert above
letter (ar)

Licensing jurisdiction
(state) or other
licensing authority
(if applicable)

Bar, license, certification,

registration, or enrollment
number (if applicable).
See instructions for Part II for
more information.

Signature

Date

Form 2848 (Rev. 7-2014)

Form

OMB No. 1545-1165

8821

Tax Information Authorization

For IRS Use Only

Received by:
Name

a Information

(Rev. October 2012)

Department of the Treasury
Internal Revenue Service

about Form 8821 and its instructions is at www.irs.gov/form8821.

a Do not sign this form unless all applicable lines have been completed.
a To request a copy or transcript of your tax return, use Form 4506, 4506-T, or 4506T-EZ.

Telephone
Function
Date

1 Taxpayer information. Taxpayer must sign and date this form on line 7.
Taxpayer identification number(s)

Taxpayer name and address (type or print)

Daytime telephone number

Plan number (if applicable)

2 Appointee. If you wish to name more than one appointee, attach a list to this form.
CAF No.
Name and address
PTIN
INA E DWA R DS or DONIK A V L A DIMIR OV A or A S HL E Y B R OWN
Telephone No.
1 888 203 8900
C/O TAXBACK INC
Fax No.
1 312 873 4202
333 N MIC HIG A N A V E , S T E 2415
Check if new: Address
Telephone No.
Fax No.
C HIC A G O, IL 60601-4105
3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information for the tax matters listed on this
line. Do not use Form 8821 to request copies of tax returns.
(a)
Type of Tax
(Income, Employment, Payroll, Excise, Estate,
Gift, Civil Penalty, etc.) (see instructions)

INDIV IDUA L INC OME T A X

F IC A T A X

(b)
Tax Form Number
(1040, 941, 720, etc.)

(c)
Year(s) or Period(s)
(see the instructions for line 3)

1040, 1040NR

2014,2013,2012,2011

843, 8316

2014,2013,2012,2011

(d)
Specific Tax Matters (see instr.)

4 Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific
use not recorded on CAF, check this box. See the instructions. If you check this box, skip lines 5 and 6 . . . . . . a
5 Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):
a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing
basis, check this box
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
Note. Appointees will no longer receive forms, publications and other related materials with the notices.
b If you do not want any copies of notices or communications sent to your appointee, check this box . . . . . . . a

6 Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all prior
authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want
to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect
and check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
To revoke this tax information authorization, see the instructions.
7 Signature of taxpayer. If signed by a corporate officer, partner, guardian, executor, receiver, administrator, trustee, or
party other than the taxpayer, I certify that I have the authority to execute this form with respect to the tax matters and tax
periods shown on line 3 above.
a IF

NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.

a DO

NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

02/26/15
mm/dd/yy

Signature

Date

Print Name

Title (if applicable)

PIN number for electronic signature

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Cat. No. 11596P

Form 8821 (Rev. 10-2012)

Form

8822

Change of Address
(For Individual, Gift, Estate, or Generation-Skipping Transfer Tax Returns)

(Rev. October 2014)

Department of the Treasury
Internal Revenue Service

Part I

a Please

OMB No. 1545-1163

type or print. a See instructions on back. a Do not attach this form to your return.
a Information about Form 8822 is available at www.irs.gov/form8822.

Complete This Part To Change Your Home Mailing Address

Check all boxes this change affects:

1

Individual income tax returns (Forms 1040, 1040A, 1040EZ, 1040NR, etc.)
a If your last return was a joint return and you are now establishing a residence separate from the spouse with whom
a
you filed that return, check here . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gift, estate, or generation-skipping transfer tax returns (Forms 706, 709, etc.)
a For Forms 706 and 706-NA, enter the decedents name and social security number below.
a

Decedents name

Social security number

3a

Your name (first name, initial, and last name)

3b

Your social security number

4a

Spouses name (first name, initial, and last name)

4b

Spouses social security number

5a

Your prior name(s). See instructions.

5b

Spouse's prior name(s). See instructions.

6a

Your old address (no., street, apt. no., city or town, state, and ZIP code). If a P.O. box, see instructions. If foreign address, also complete spaces below,
see instructions.

Foreign country name

6b

Foreign province/county

Spouses old address, if different from line 6a (no., street, apt. no., city or town, state, and ZIP code). If a P.O. box, see instructions. If foreign address, also
complete spaces below, see instructions.

Foreign province/county

Foreign country name

Foreign postal code

Foreign postal code

New address (no., street, apt. no., city or town, state, and ZIP code). If a P.O. box, see instructions. If foreign address, also complete spaces below, see
instructions.

C/O TAXBACK, IDA BUSINESS & TECHNOLOGY PARK, RING ROAD, KILKENNY,
Foreign country name

Foreign province/county

Foreign postal code

IRELAND

Part II

Signature

Daytime telephone number of person to contact (optional) a

Your signature

Date

If joint return, spouses signature

Date

For Privacy Act and Paperwork Reduction Act Notice, see back of form.

FF

FF

Sign
Here

02/26/15
mm/dd/yy

Signature of representative, executor, administrator/if applicable

Date

Title
Cat. No. 12081V

Form

8822

(Rev. 10-2014)

USA TAX REGISTRATION

SPANISH VERSION

CUSTOMER AGREEMENT
El contrato con el cliente es la base de la relacin entre Taxback y usted. Es un documento importante, por favor lea los puntos
en su totalidad y asegrese de comprenderlos antes de firmar. / The customer agreement forms the basis of the relationship between
Taxback and you. It is an important document, please read the points in full and ensure you understand them, before signing.

Yo confirmo que / I confirm that:

1. Entiendo que taxback.com es el nombre comercial de Taxback Inc., Chicago, USA, y por la presente contrato a Taxback Inc. para llevar a cabo los servicios

descritos en la misma / I understand that taxback.com is a trading name for the services of Taxback Inc., Chicago, USA, and hereby contract with Taxback Inc. to
carry out the services described herewith.

2. Entiendo que Taxback Inc utilizar a su empresa madre Taxback y sus subsidiarias y compaas afiliadas para reunir informacin referente a los servicios,
donde sea necesario y que el contrato permanece con Taxback Inc por la duracin del servicio. / I understand that Taxback Inc will utilize its parent company
Taxback and its subsidiary and affiliate companies to gather information regarding the services where necessary and that the contract remains with Taxback Inc
for the duration of the service.
3. He firmado los poderes necesarios para autorizar a Taxback. Inc, y / o sus subsidiarias comercializando como taxback.com y en adelante referido como
el Agente, a preparar esta solicitud de reembolso de impuestos y representarme ante las Autoridades Tributarias de los EE.UU. (IRS and State Tax
Authorities). / I have signed the necessary power of attorneys to authorize Taxback. Inc, and / or its subsidiary undertakings trading as taxback.com and referred
to hereafter as the Agent, to prepare this tax return and represent me before the US Tax Authorities (IRS and State Tax Authorities).
4. Autorizo al Agente a recibir toda correspondencia de las Autoridades Tributarias de los EE.UU. en nombre mo.
I authorize the Agent to receive all correspondence from the US Tax Authorities on my behalf.
5. Entiendo que se requieren recibos para respaldar cualquier reclamo que haga por gastos.
I understand that receipts are required to substantiate any claim that I make for expenses.
6. Deseo hacer opcin de la oferta sin pagos de antemano cuando acepte el servicio. Para poder seleccionar esta opcin, entiendo que el cobro de la tarifa tendr
que ser pagada por mi cuando el reembolso haya sido emitido por las Autoridades Tributarias de EE.UU / I want to avail of the offer to pay no fee up-front when
I sign up for the service. In order to avail of this option, I understand that the fee will need to be paid by me when the refund has been issued by the US Tax Authorities.
7. Autorizo al Agente para recibir mi cheque(s) de reembolso de las Autoridades Tributarias.
I authorize the Agent to receive my refund cheque(s) from the Tax Authorities.
8. Estoy de acuerdo adems, que una vez que el agente reciba mi cheque (s) de reembolso, lo endosar rpidamente con el fin de permitir al agente deducir
la cuota necesaria y que me enve la cantidad restante. / I further agree that once the Agent receives my refund cheque(s), I will promptly endorse the cheque in
order to allow the agent to deduct the necessary fee and to send me the remaining amount.
9. Entiendo que una vez que se haya procesado mi reembolso, ser contactado por un Asesor con referencia a las opciones de pago para recibir mi
reembolso y podr brindar mis detalles bancarios. / I understand that once my refund is processed, I will be contacted by the Agent with regard to payment
options for receiving my refund and will be able to provide my bank details.
10. Si el agente eligiera por cualquier razn no aceptar mi endoso en el cheque, entiendo y acepto que pagar la comisin y cobrar el cheque de reembolso
de la oficina tributaria yo mismo./ Should the Agent choose for any reason not to accept my endorsement on the cheque, I understand and agree that I will pay
the fee due and will cash the tax office refund cheque myself.
11. En caso reciba mi reembolso directamente de otra fuente que no sea el Agente, entiendo y estoy de acuerdo que pagar la tarifa correspondiente al
Agente por el trabajo realizado. / Should I receive the refund directly from any other source other than the Agent, I understand and agree that I will pay the fee
due to the Agent for the work completed.
12. En caso de estar debiendo impuestos por otros aos fiscales, y las Autoridades Tributarias de los EE.UU. descuenten esta deuda pendiente de otros aos
fiscales, entiendo y estoy de acuerdo que necesitar pagar al Agente la tarifa de procesamiento por cada ao fiscal que se haya solicitado un reembolso.
Should I owe income tax for other tax years, and the US Tax Authorities deduct this owed money from the refund due for other tax year (s), I understand and
agree that I need to pay the Agent processing fee for each tax year for which a tax return was processed.
13. Entiendo que las Autoridades Tributarias de los EE.UU. tomarn la decisin final sobre el valor de cualquier reembolso que se deba. Entiendo que el Agente
brindar el mejor clculo Estimado posible basndose en las actuales leyes tributarias y la informacin proporcionada, sin embargo este clculo es solo un
estimado, no una garanta. / I understand that the US Tax Authorities will make the final decision on the value of any refund due. I understand that the Agent will
provide the best estimation possible based on current tax law and information given, however this is estimation only, not a guarantee.
14. Estoy de Acuerdo con los trminos y las condiciones de servicios, tal y como descritos en lnea en www.taxback.com, y como podran ser modificados en algn
momento, y con las tarifas del Agente que representan los servicios del cual he aceptado del Agente. / I agree to and accept the terms and conditions of service
as written online at www.taxback.com and to any changes in the terms and conditions which Taxback Inc may affect from time to time, and to the fees of the
agent which represents the services I have requested and which are provided by Taxback Inc and/or its affiliate companies.
15. Entiendo que la informacin recolectada por escrito y / o verbalmente para los servicios de presentar una solicitud de reembolso de impuestos podra ser
utilizada para propsitos de auditora interna de taxback.com y proporcionada a las Autoridades Tributarias de los EE.UU. (IRS and State Tax Authorities)
para propsitos de auditoria externa, sujeto a la legislacin correspondiente a la proteccin de datos. / I understand that information collected in writing
and/or verbally for US tax return filing services can and may be used for internal auditing purposes by taxback.com and provided to the US Tax Authorities
(IRS and State Tax Authorities) for external auditing purposes, subject to relevant data protection legislation.
16. Confirmo que le he brindado al Agente toda la informacin necesaria y que haya estado a mi disposicin.
I confirm that I have given the Agent all information needed and available to me.
17. Me comprometo a actualizar con el Agente, cualquier detalle de contacto mo que cambie.
I commit to updating the Agent of any change in my contact details.
18. Entiendo que taxback.com enviar mi aplicacin a la oficina fiscal relevante tan pronto como yo haya sido informado del monto de reembolso y haya
enviado todos los documentos necesarios. Si desear cancelar mi aplicacin, contactar a taxback.com inmediatamente. Entiendo que aunque
taxback.com har todo el esfuerzo para cancelar mi aplicacin, esto puede no ser posible. / I understand that taxback.com will submit my application to the
relevant tax office as soon as I have been informed of the refund amount and have sent all necessary documentation. Should I wish to cancel my application,
I will contact taxback.com immediately. I understand that while taxback.com will make every effort to recall my application, this may not be possible.

Nombre en imprenta
Name in print

Nmero de Social Security

KATIA CONDORI MAMANI

Fecha
Date

052 - 41 - 0237

Social Security Number

taxback.com, 333 N. Michigan Avenue, Suite 2415, Chicago, IL, 60601

26/02/15
dd / mm / yy

Firma
Signature

www.taxback.com

USA TAX REGISTRATION

SPANISH VERSION

POWER OF ATTORNEY
Please only fill out the fields where you see the

Katia Condori Mamani

Taxpayer Name
Date of birth

indicated.

26/02/15

dd / mm / yy

SSN (last 4 digits)

hereby appoint the following representative as attorney- in fact:

Taxback Inc., 333 N. Michigan Avenue, Suite 2415, Chicago IL 60601
to act as my legal representative before my employer(s), to perform any and all acts I can perform
with regards to the following matters:
A) to review, receive and collect original and copied W-2 forms, tax information statements, earnings
statements and any other payroll, tax and income related forms and information.
B) to deal with my Social Security and MediCare (FICA) tax rebate and to receive tax information and
refund cheques issued in my name at the address stated above.
This Power of Attorney shall become effective immediately on the date signed and shall terminate on
the date these matters are completed.
This Power of Attorney revokes all prior Power of Attorney(s) filed.
I am fully informed as to all the contents of this form and understand the full importance of granting
these powers to my representative.

Taxpayer Signature

taxback.com, 333 N. Michigan Avenue, Suite 2415, Chicago, IL, 60601

Date

26/02/15
dd / mm / yy

www.taxback.com

USA TAX REGISTRATION

SPANISH VERSION

CONSENTIMIENTO DE DIVULGACIN DE INFORMACIN

DE LA DECLARACIN DE IMPUESTOS
Segn IRC Seccin 7216
CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION
under IRC Section 7216

Para garantizar que su declaracin de impuestos se realice de manera correcta y que acate con la ley, nos basamos
en la pericia y experiencia de nuestro equipo tributario internacional. En conformidad con Treas. Reg. Section 301.72163 y Rev. Proc. 2013-14, le solicitamos que nos brinde su consentimiento para que podamos compartir y almacenar su
informacin, incluyendo su SSN (Social Security Number) y la informacin tributaria de su empleo, con nuestro equipo
tributario internacional para asegurar que su declaracin de impuestos cumpla con la ley. /To ensure your tax return is prepared

in a compliant and correct manner, we draw on the expertise and experience of our international tax team. In line with Treas. Reg. Section
301.7216-3 and Rev. Proc. 2013-14, we request that you provide consent to us so that we can share and store your data, including your SSN and
employment and tax data, with our international tax team to ensure your tax return is compliant.

La ley federal requiere que se le de el presente formulario de consentimiento. A menos que lo autorice la ley,
nosotros no podemos divulgar, sin su consentimiento, su informacin de declaracin de impuestos a terceros (se considera
como terceros a nuestros colegas internacionales, ya que son empleados de las oficinas internacionales de Taxback y no
de Taxback Inc. directamente) para otros propsitos que no sean la preparacin y presentacin de su declaracin de
impuestos y, en ciertas circunstancias limitadas, para propsitos relacionados con la preparacin de la declaracin de
impuestos. /Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose, without your consent, your

tax return information to third parties (our international colleagues will qualify as third parties as they are employed by Taxback international
offices, not by Taxback Inc. directly) for purposes other than the preparation and filing of your tax return and, in certain limited circumstances, for
purposes involving tax return preparation.

El presente consentimiento de divulgacin puede resultar en que se brinde su informacin de declaracin de

impuestos a las personas encargadas de preparar dicha declaracin que se encuentran fuera de los Estados Unidos,
incluyendo su informacin de identificacin personal tal como su Social Security Number (SSN). Tanto las personas que
se encargan de preparar su declaracin de impuestos en EE.UU. y fuera de EE.UU., las cuales recibirn su SSN, mantendrn
una adecuada proteccin de su informacin (tal como lo requieren las normas de la 26 U.S.C. Section 7216) para proteger
su privacidad y prevenir el acceso no autorizado a la informacin de la declaracin de impuestos. / This consent to disclose

may result in your tax return information being disclosed to a tax return preparer located outside the United States, including your personally
identifiable information such as your Social Security Number (SSN). Both the tax return preparer in the United States that will disclose your SSN
and the tax return preparer located outside the United States which will receive your SSN maintain an adequate data protection safeguard (as
required by the regulations under 26 U.S.C. Section 7216) to protect privacy and prevent unauthorized access of tax return information.

Si usted cree que su informacin de declaracin de impuestos ha sido divulgada o utilizada de manera inapropiada
sin la autorizacin de la ley o sin su permiso, usted puede contactarse con la Treasury Inspector General for Tax Administration
(TIGTA) por telfono al 1-800-366-4484, o por email a complaints@tigta.treas.gov. / If you believe your tax return information has

been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General
for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov.

Si usted est de acuerdo con que Taxback divulgue su informacin de declaracin de impuestos, incluyendo su SSN,
al personal de Taxback y a sus afiliados para brindar asesora en la preparacin de su declaracin de impuestos de ingreso
personal, por favor firme el presente formulario y escriba su nombre en letra mayscula. / If you agree to allow Taxback to disclose

your tax return information, including your SSN, to Taxback staff and affiliates for the purpose of providing assistance in the preparation of your
individual income tax returns, please sign this form and print your name in capital letters.

Nombre en imprenta
Name in print

KATIA CONDORI MAMANI

Firma
Signature

Fecha
Date

26/02/15
dd / mm / yy

taxback.com, 333 N. Michigan Avenue, Suite 2415, Chicago, IL, 60601

www.taxback.com 10