Authorization For Release Of Financial Information (Including Account Status Of A Taxfiler/licensee) Form - Portland
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1Terri Williams, Manager
Licenses & Tax Division
C
P
Revenue Bureau
ITY OF
ORTLAND
111 SW Columbia, Room 600
OFFICE OF MANAGEMENT AND FINANCE
Portland, Oregon 97201-5840
(503) 823-5157
Tom Potter, Mayor
FAX (503) 823-5192
Kenneth L. Rust, Chief Administrative Officer
TTY (503) 823-6868
Sue Klobertanz, Revenue Bureau Director
Authorization for Release of Financial Information
(Including Account Status of a Taxfiler/Licensee)
1)* Name of taxfiler/licensee as reported on Federal Form 1040, 1120S, Oregon Form 20, etc.:
2) DBA of taxfiler/licensee:
3) Account #:
4)* Federal Tax ID # or Social Security #:
5)* Name of individual making this request (must be someone who is currently authorized to
sign the federal tax return of 1 above). Also include the address, phone #, and/or fax # to
which this information can be released:
6) Name of party to whom financial information will be released if different from 5 above (a
non-officer employee of 1 above, a lending institution, etc.). Also include the address, phone #,
and/or fax # to which this information can be released:
7)* Description of information to be released:
Taxfiler/licensee account status (Is the account current according to Bureau records?)
Prepayments per Bureau records for the tax year ending ___/___/___
Other (please explain)
I declare that I am either the taxpayer whose name is shown on 1 above or an individual currently
authorized to sign the federal tax returns for 1 above or a paid preparer (including employees of the paid
preparer) currently authorized to sign the federal tax returns for 1 above.
8)* Signature of individual from 5 above:
Signed_____________________________________Date____________Title____________________________
Address____________________________________________Telephone_______________________________
This section is only to completed by a representative of the City of Portland Revenue Bureau
The taxfiler/licensee on 1 above is currently in full compliance with the City of Portland Business
License Law and Multnomah County Business Income Tax Law.
For the tax year ended ___/___/___, the prepayments for the taxfiler/licensee on 1 are as follows: line
13 (County) = $_____________, line 23 (City) = $_____________.
Other:
Signed_______________________________________Date______________Title______________________________
*Required
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