Form 821 - Withholding Tax Information Authorization printable pdf download

Form 821 - Withholding Tax Information Authorization

STATE OF ARIZONA • DEPARTMENT OF REVENUE

ARIZONA FORM

Withholding Tax Information Authorization

821

1. Taxpayer Information: Taxpayer must sign and date this form on line 5.

Taxpayer Name

Daytime Telephone Number

Arizona Withholding Tax Number

(

)

Address

Federal Employer Identiﬁ cation Number

City

State

Zip Code

Social Security Number

2. Appointee Information

Name

Identiﬁ cation Number

Address

Telephone Number

(

)

City

State

Zip Code

Fax Number

(

)

3. Authorization

The appointee is authorized to inspect and/or receive conﬁ dential Arizona withholding tax information for the following tax year(s) or period(s):

4. Retention/Revocation of Withholding Tax Information Authorization

This withholding tax information automatically revokes all earlier tax information authorizations on ﬁ le with the Arizona Department of Revenue for the

same years or periods covered by this document. If you do not want to revoke a prior tax information authorization, check this box................................

You must attach a copy of any tax information authorization you want to remain in effect.

5. Signature of or for Taxpayer

I hereby certify that the Director of the Arizona Department of Revenue, is authorized to release any and all Arizona withholding tax information in department

ﬁ les concerning the undersigned taxpayer and relieve said Director, or department representative, of any liability whatsoever for releasing such withholding

tax information to the appointee speciﬁ ed by this withholding tax information authorization. If signed by a corporate ofﬁ cer or partner, I certify that I have the

authority to execute this withholding tax information authorization on behalf of the taxpayer(s).

If this withholding tax information authorization is not signed, it will be returned.

Print Name

Signature

Date

Mail to: Arizona Department of Revenue, 1600 West Monroe, Phoenix, AZ 85007

ADOR 91-0076 (02)