Form 315 - Notice Of Transfer Of Alaska Oil And Gas Production Tax Credit Certificate Page 2

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Alaska

315

Waiver of Confidentiality for Oil and Gas

Production Tax Credit Certificates under

AS 43.55.023 and 43.55.025

Federal EIN

Date

Taxpayer Name

Mailing Address

City

State

Zip Code

Contact Person

Title

Contact Phone Number

Contact Fax Number

Contact Email Address

The above named taxpayer hereby waives its confidentiality rights under AS 43.05.230(a) and authorizes the Department of Revenue to disclose to or

request from:

Name: __________________________________________________________________________________________

Company:________________________________________________________________________________________

Phone Number: ___________________________________________________________________________________

its officers and employees, limited to the following information:

AS 43.55.023 or 43.55.025 Alaska Oil and Gas Production Tax Credit Certificate Number . . . . . . . . . . . . . . . . .

Holder of certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tax credit certificate amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Date issued . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AS 43.05.230(a) provides:

It is unlawful for a current or former officer, employee, or agent of the state to divulge the amount of income or the particulars set out or disclosed

in a report or return made under this title, except (1) in connection with official investigations or proceedings of the department, whether judicial or

administrative, involving taxes due under this title.

I declare under penalty of perjury that I am authorized to sign on behalf of the taxpayer this application and each attachment

has been examined by me and to the best of my knowledge and belief is true, correct and complete.

Signature

Date

Printed Name

Printed Title

This form is available online at

Submit completed forms via the Department’s Online Tax

Information System (OTIS) at .

Retain a copy for your records

315