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

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General Disclosure/Representation Authorization Form
ARIZONA FORM
285
A
D
R
RIZONA
EPARTMENT OF
EVENUE
Effective June 1, 2000
1. TAXPAYER INFORMATION - Please print or type.
Enter only those that apply:
Taxpayer name(s)
Federal Employer Identifi cation Number
Present address - number and street, rural route, apartment/suite no.
Social Security Number(s)
City, town or post offi ce
State
Zip Code
Arizona Withholding Number
Daytime telephone number
Arizona Transaction Privilege Tax License Number
(
)
2. APPOINTEE INFORMATION
Provide one of the following identifi cation numbers:
Name
State and State Bar Number
Present address - number and street, rural route, apartment/suite no.
State and Certifi ed Public Accountant Number
City, town or post offi ce
State
Zip Code
Internal Revenue Service Enrolled Agent Number
Daytime telephone number
Social Security or other ID number (provide number and type)
(
)
3. TAX MATTERS. The appointee is authorized to receive confi dential information for the tax matters listed below.
TAX TYPE
YEAR(S) OR PERIOD(S)
TYPE OF RETURN/OWNERSHIP
! 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
! Withholding Tax
! Limited Liability Company
! Limited Liability Partnership
! Estate
! Other (specify tax type):
Specify type of return(s)/ownership:
____________________
4. SCOPE OF AUTHORIZATION. By signing this form, I hereby authorize the Department to release confi dential information of the taxpayer(s) named above
(“Taxpayer”) to the appointee named above (“Appointee”) for the tax type and tax year(s)/period(s) specifi ed above.
Additional Representational Authority: In addition to authorizing the release of the confi dential information of Taxpayer, the following additional representa-
YES
NO
tional powers are granted to the Appointee. Please check the applicable boxes:
i. Appointee shall have the power to sign a statute of limitations waiver on Taxpayer’s behalf.............................................................
i.
ii. Appointee shall have the power to execute a protest of a defi ciency assessment or agreement thereto on Taxpayer’s behalf ........
ii.
iii. Appointee shall have the power to request a formal hearing on Taxpayer’s behalf............................................................................
iii.
iv. Appointee shall have the power to execute a closing agreement on Taxpayer’s behalf.....................................................................
iv.
v. Other (please specify): ___________________________________________________________________________________
v.
______________________________________________________________________________________________________
vi. This instrument shall be a POWER OF ATTORNEY granting Appointee the power to represent Taxpayer, including, pursuant to
vi.
Rule 31(a)(3) and (4), Ariz. R. Supreme Court, representation at any formal administrative tax proceedings with regard to the
above-mentioned tax matters and tax year(s)/periods(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 fi le with the Arizona Department of Revenue unless the following revocation box is checked...............................................
5.
The revocation will be effective as to all earlier authorizations and Powers of Attorney on fi le with the Department of Revenue except
those specifi ed (please specify): ______________________________________________________________________________
6. SIGNATURE OF OR FOR TAXPAYER. I hereby certify that the Arizona Department of Revenue is authorized to release any and all confi dential
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
DATE
SIGNATURE
DATE
______________________________________________________________
_____________________________________________________________
PRINT NAME
PRINT NAME
______________________________________________________________
_____________________________________________________________
TITLE
TITLE
ADOR 03-0029 (01) slw

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