Form Dtf-65 - Authorization For Release Of Tax Return Information printable pdf download

Form Dtf-65 - Authorization For Release Of Tax Return Information

DTF-65 (1/99)

Authorization for Release of Tax Return Information

To: Disclosure Officer

CASD/PATS

NYS Tax Department

WA Harriman Campus

Building 9, Room 381

Albany NY 12227

From:

I, __________________________________________________ (___________________________________________) of

(Social Security or Employer Identification Number)

(Print Name of Taxpayer)

________________________________________________________________________________________________________

(Address)

hereby authorize and request that the New York State Department of Taxation and Finance release information verifying the

timely filing of my state income tax returns for the years __________ , _________ and _________ to the following:

___________________________________________________________________________________________________

Name

__________________________________________

_________________________________________

___________________________________

Address

Taxpayer Signature

__________________________________________

___________________________________

Taxpayer telephone number

Title

State of New York

County of ____________________

On this ____ day of _______________ , 20___ , before me personally appeared ______________________________________

to me known, and known by me to be the person who executed the foregoing instrument, and (s)he acknowledged to me that (s)he

executed the same.

______________________________________

Notary Public/Commissioner of Deeds

Notary Number _____________________

County Qualified ____________________

Expiration Date _____________________

Form Dtf-65 - Authorization For Release Of Tax Return Information