Form 285 - General Disclosure/representation Authorization Form - Arizona Department Of Revenue

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285

General Disclosure/Representation

Form

Authorization Form

(Effective 6/1/2000)

Arizona Department of Revenue

1. Taxpayer Information.

Enter only those that apply

Taxpayer name(s) and address (please print or type)

Federal Employer Identification Number

Social Security Number(s)

Arizona Withholding Number

Daytime telephone number

Arizona Transaction Privilege Tax License Number

2. Appointee Information.

Provide one of the following identification numbers

Name and address

State and State Bar Number

State and Certified Public Accountant Number

Internal Revenue Service Enrolled Agent Number

Social Security or other ID number (provide number and type)

Daytime telephone number

3. Tax Matters. The appointee is authorized to receive confidential information for the tax matters listed below.

Year(s) or period(s)

Type of return/ownership

Tax type

Income Tax

Individual Joint Return

Individual Single Return

Corporation

Partnership

Fiduciary-Trust

Fiduciary-Estate

Transaction Privilege

Individual/Sole Proprietorship

Partnership

Corporation

Trust

and Use Tax

Limited Liability Partnership

Withholding Tax

Limited Liability Company

Estate

Other (Specify tax type)

Specify type of returns(s)/ownership

4. Scope of Authorization. By signing this form, I hereby authorize the Department to release confidential information of the taxpayer(s) named above

(“Taxpayer”) to the appointee named above (“Appointee”) for the tax type and tax year(s)/period(s) specified above.

Additional Representational Authority: In addition to authorizing the release of the confidential information of Taxpayer, the following additional

representational powers are granted to the Appointee (please check the applicable boxes).

(Yes)

(No)

…….Appointee shall have the power to sign a statute of limitations waiver on Taxpayer’s behalf.

…….Appointee shall have the power to execute a protest of a deficiency assessment or agreement thereto on Taxpayer’s behalf .

ii.

…….Appointee shall have the power to request a formal hearing on Taxpayer’s behalf.

iii.

…….Appointee shall have the power to execute a closing agreement on Taxpayer’s behalf.

iv.

…….Other (please specify)

…….This instrument shall be a POWER OF ATTORNEY granting Appointee the power to represent Taxpayer, including,

vi.

pursuant to Rule 31(a)(3) & (4) Ariz. R. Supreme Court, representation at any formal administrative tax proceedings with

regard to the above-mentioned tax matters and tax year(s)/period(s). In addition to any limitations indicated above, the

following additional 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 file with the Arizona

Department of Revenue unless the following revocation box is checked……………………………………………………………………………………...

The revocation will be effective as to all earlier authorizations and Powers of Attorney on file with the Department of Revenue except those specified (please

specify) ________________________________________________________________________________________________________________________

6. Signature of or for Taxpayer. I hereby certify that the Arizona Department of Revenue is authorized to release any and all confidential information

concerning the above-mentioned Taxpayer. By signing this form, I certify that I have the authority, within the meaning of A.R.S. § 42-2003(A), to execute this

authorization form on behalf of the above-mentioned corporation(s), limited liability company(ies), trust(s), estate(s), partnership(s), and/or individual(s). 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

Title

Date

Title

Date

Print name

ADOR 03-0029 (4/00)