Form 500 - Authorization To Disclose Tax Information & Designation Of Representative

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FORM 500 - AUTHORIZATION TO DISCLOSE TAX

INFORMATION & DESIGNATION OF REPRESENTATIVE

OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER

SFN 28258 (12-2013)

Taxpayer Information

Name of Individual, Estate, Trust, Partnership, Corporation, LLP, or LLC

Telephone No.

Federal Identification Number*

Name of Spouse, Fiduciary or Personal Representative (if applicable)

Telephone No.

Spouse's Federal Identification Number

Street Address

City

State

Zip Code

Designated Individual (or Firm) (Do Not Complete if Checking Box D Below.)

Federal Identification Number

Name of Individual (or Firm)

Fax No.

E-mail Address

Telephone No.

Street Address

City

State

Zip Code

Check the appropriate box(es):

A. Authorization To Disclose Tax Information.

The Tax Commissioner is authorized to disclose confidential tax information on file

with the Office of State Tax Commissioner to the above-designated individual or firm with respect to the following matters:

Type of Tax

Form Number

Tax Year or Period

B. Designation of Representative.

The Tax Commissioner is notified that the above-designated individual or firm has been authorized

to represent the above-named taxpayer(s) before the Office of State Tax Commissioner with respect to the following matters:

Type of Tax

Form Number

Tax Year or Period

This designation of representative also authorizes the Tax Commissioner to disclose confidential tax information on file with the Office of

State Tax Commissioner to the representative. The representative is authorized to perform all acts that the taxpayer can perform except

that only an individual admitted and licensed to practice law in North Dakota may sign a complaint, represent the taxpayer in a formal

administrative review under North Dakota Century Code ch. 28-32, or represent the taxpayer in any court proceeding.

C. Authorization To Disclose Tax Information Using Facsimile or E-mail.

The Tax Commissioner is authorized to use facsimile

or e-mail, or both, to disclose confidential tax information on file with the Office of State Tax Commissioner to the above-designated

individual or firm with respect to the above-identified matters.

D. Revocation.

The Tax Commissioner is notified that all authorizations and designations previously made by the above-named taxpayer(s)

are revoked, and that no new authorization or designation is being made at this time. (If this box is checked, Do Not check Box A, Box B,

or Box C.)

This authorization to disclose tax information or a designation of representative does not cover the routine mailing of tax forms, refund checks,

original notices (e.g, a Notice of Determination), or other original written communications.

This authorization to disclose tax information or a designation of representative takes effect upon receipt by the Office of State Tax Commissioner

and remains in effect until revoked by the taxpayer.

Signature of Taxpayer(s)

If signed by a corporate officer, partner, governor, manager, or fiduciary on behalf of taxpayer, I certify I have authority to sign this form on behalf

of the taxpayer.

Signature

Title

Date

Printed Signature

Date

Signature of Spouse, if applicable

Printed Spouse's Signature

For Office Use Only