Form Ador 25-0002f - Tax Clearance Application - 2009
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1Instructions
Arizona Department of Revenue • Collections Administrative Support
PO Box 29070 • Phoenix, AZ 85038
Telephone: (602) 716-6234
TAX CLEARANCE APPLICATION
1. Applicant Information:
APPLICANT NAME
DAYTIME PHONE NO. (with area code)
STREET ADDRESS
CITY
STATE
ZIP CODE
2. Tax Clearance Purpose: Check only one box.
CERTIFICATE OF COMPLIANCE FOR DISSOLUTION OR WITHDRAWAL:
Dissolution of Corporation (not applicable to estate, trust, or individual application types)
Withdrawal from Arizona (not applicable to estate, trust, or individual application types)
LETTER OF GOOD STANDING:
Gaming
Renewable Energy Tax Incentive
Healthy Forest Certifi cation
Residency
Motion Picture Production Incentive
Sale of Business
Personal
Other:
3. Application Type: Check only one box and provide tax identifi cation number(s).
Corporation
Federal Employer I.D. No./Taxpayer I.D. No.
S Corporation
Partnership
AZ Transaction Privilege License No.
Tax Exempt Organization
Limited Liability Company
AZ Withholding Tax License No.
Limited Liability Partnership
Estate
Federal Employer I.D. No./Social Security No.
Trust
Individual
AZ Transaction Privilege License No.
AZ Withholding Tax License No.
4. Signature
PRINT NAME
PRINT SPECIFIC TITLE (Corporate Offi cer, Partner, Individual)
SIGNATURE
DATE
5. Mail application to:
Arizona Department of Revenue, Collections Administrative Support,
PO Box 29070, Phoenix, AZ 85038
• Do not fax the application. Faxed applications will not be processed.
• Be sure to sign the application. Unsigned applications will not be processed.
• If your application cannot be approved, you must clear all defi ciencies and resubmit an application.
• POWER OF ATTORNEY: If this application is submitted by anyone other than a corporate offi cer, general partner, or
individual (sole proprietor), Arizona Form 285, General Disclosure/Representation Authorization Form, is required. Visit
our web site at and click on the Forms link to obtain Form 285.
ADOR 25-0002f (9/09)
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Parent category: Financial