Form 285b - Disclosure Authorization Form - Arizona Department Of Revenue
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1Disclosure Authorization Form
285B
Form
This form authorizes the Department to release confidential information of the taxpayer(s)
named below to the appointee(s) named below for the tax type(s) specified below. This form
(Effective 4/1/2000)
is not a Power of Attorney and does not grant the appointee(s) any powers of representation.
Arizona Department of Revenue
1. Taxpayer Information.
Enter only those that apply
Taxpayer name (please print or type)
Federal Employer Identification Number
Arizona Withholding Number
Daytime telephone number
Arizona Transaction Privilege Tax License Number
2. Appointee Information.
2nd Appointee Information if applicable
Name
Name
Address
Address
Daytime telephone number
Daytime telephone number
Social Security or other ID number (please specify type)
Social Security or other ID number (please specify type)
3. Tax Matters. The appointee is authorized to receive confidential information for the tax type(s) listed below.
Transaction Privilege and Use Tax
Withholding Tax
4. Tax Periods. This authorization will be valid for all past years and four future years unless the following box is checked
and tax periods specified . . .
Please specify more limited periods ____________________________________________
5. Revocation of earlier Authorization(s). This disclosure authorization form does not revoke any prior Power of Attorney
or other authorization forms on file with the Department.
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), 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).
Date
Signature
Print name
Title
ADOR 03-0032 (4/00)
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