Form Ttb F 5000.19 - Tax Information Authorization - Department Of The Treasury

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OMB No. 1513-0001 (05/31/2017)
DEPARTMENT OF THE TREASURY
ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)
TAX INFORMATION AUTHORIZATION
(PURSUANT TO TITLE 26 OF THE UNITED STATES CODE AND THE FEDERAL ALCOHOL ADMINISTRATION ACT)
IMPORTANT - Please read instructions before completing this form.
(Prepare in duplicate)
PART I - AUTHORIZATION
1. PRINCIPAL
2. ADDRESS (Number, Street, City, State, ZIP Code)
3. BUSINESS IN WHICH ENGAGED
5. ADDRESS (Number, Street, City, State, ZIP Code)
4. NAME OF REPRESENTATIVE (Attorney, Certified Public
Accountant, or Agent)
6. THE ABOVE-NAMED REPRESENTATIVE IS HEREBY AUTHORIZED TO: (See Instruction 3)
a.
Receive from, or inspect in, any office of the Director, National Revenue Center, and/or the Administrator, Alcohol and Tobacco
Tax and Trade Bureau, any confidential information on behalf of the principal.
b.
Receive from, or inspect in, such office(s) confidential information with respect to:
.
c.
Receive the original of any ruling (or correspondence in connection therewith) on behalf of the principal.
d.
Receive copies of notices and other written communications addressed to the principal involving confidential tax matters.
7. THE SIGNATURE OF THE REPRESENTATIVE HEREBY AUTHORIZED TO RECEIVE CONFIDENTIAL INFORMATION
8. SIGNATURE OF OR FOR PRINCIPAL(S) (If a corporate officer, partner, or fiduciary signs below on behalf of the principal, the following statement
of authority applies)
I certify that I have the authority to execute this Tax Information Authorization on behalf of the principal.
CORPORATE
DATE
SIGNATURE
TITLE (If applicable)
SEAL
(If applicable)
SIGNATURE
TITLE (If applicable)
DATE
SIGNATURE
TITLE (If applicable)
DATE
SIGNATURE
TITLE (If applicable)
DATE
PART II - DECLARATION BY ATTORNEY OR CERTIFIED PUBLIC ACCOUNTANT (See Instruction 5)
9. I declare that I am not currently under suspension or disbarment from practice before the Alcohol and Tobacco Tax and Trade Bureau; that
.
a.
I am a member in good standing of the bar of the highest court of
b.
I am qualified to practice as a certified public accountant in
.
and; that I am authorized to represent
SIGNATURE
DATE
TTB F 5000.19 (02/2008)
(12/2009)

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