Arizona Form 285-I - Individual Income Tax Disclosure/representation Authorization Form

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Individual Income Tax Disclosure/Representation

ARIZONA FORM

285-I

Authorization Form

RIZONA

EPARTMENT OF

EVENUE

PO Box 29080, Phoenix, AZ 85038

1. TAXPAYER INFORMATION - Please print or type.

Taxpayer name(s)

Social Security Numbers

Present address - number and street, rural route, apartment

Daytime telephone number

(

)

City, town or post ofﬁ ce

State

Zip Code

2. APPOINTEE INFORMATION

Provide one of the following identiﬁ cation numbers

Name (List additional appointees on supplemental sheet)

State and State Bar Number

Address (if different from Taxpayer’s address above)

State and Certiﬁ ed Public Accountant Number

City, town or post ofﬁ ce

State

Zip Code

Internal Revenue Service Enrolled Agent Number

Social Security or other ID Number (please specify type)

Daytime telephone number

3. TAX MATTERS. The appointee is authorized to receive conﬁ dential information relating to individual income tax for the following

tax years: ________________________________________________________________________________________________

4. SCOPE OF AUTHORIZATION. By signing this form, I hereby authorize the Department to release conﬁ dential information of the taxpayer(s) named above

(“Taxpayer”) to the appointee named above (“Appointee”) for the tax type and tax year(s) speciﬁ ed above.

4a. In addition to authorizing the release of the conﬁ dential information of Taxpayer, the following additional representational powers

are granted to the Appointee. This instrument shall be a POWER OF ATTORNEY granting Appointee the power to represent

Taxpayer, including, pursuant to Rule 31(a)(3) and (4) Ariz. R. Supreme court, representation at any formal administrative tax

proceedings with regard to the above-mentioned tax matters and tax year(s). Please indicate “Yes”, or “No” ..............................

YES

The following limitations apply to Appointee’s POWER OF ATTORNEY. Please specify: _______________________________

____________________________________________________________________________________________________

5. REVOCATION OF EARLIER AUTHORIZATION(S). This authorization does not revoke any earlier authorizations or Powers of

Attorney on ﬁ le with the Arizona Department of Revenue. If you want to revoke all prior authorizations or Powers of Attorney on ﬁ le

with the Arizona Department of Revenue, please check this box. If you wish to revoke only some prior authorizations and/or Powers

of Attorney, please check the box and list below those authorizations and Powers of Attorney that you wish to remain in effect. ..........

If the box is checked, the revocation will be effective as to all earlier authorizations and Powers of Attorney on ﬁ le with the

Department of Revenue except for the following persons (please specify): _____________________________________________

_________________________________________________________________________________________________________

6. SIGNATURE OF OR FOR TAXPAYER. I hereby certify that the Arizona Department of Revenue is authorized to release any and all conﬁ dential information

concerning the above-mentioned Taxpayer. I understand that to knowingly prepare or present a document which is fraudulent or false is a class 5 felony pursuant

to A.R.S. §42-1127(B)(2).

_____________________________________________________________________

!____________________________________________________________

SIGNATURE

DATE

SIGNATURE

DATE

______________________________________________________________

_____________________________________________________________

PRINT NAME

ADOR 03-0033 (01) slw