Form 285c - Disclosure Certification Form - Arizona Department Of Revenue printable pdf download

Form 285c - Disclosure Certification Form - Arizona Department Of Revenue

Disclosure Certification Form

285C

Form

This form should be used to certify to the Department that the person named

below (“Signator”) is authorized, pursuant to A.R.S. § 42-2003(A) to receive

Effective February 29, 2000

and discuss confidential information of the taxpayer(s) named below.

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

Arizona Withholding Number

Arizona Transaction Privilege Tax License Number

Daytime telephone number

2. Signator Information.

Name

Business Address (if different fromTaxpayer’s address above)

Daytime telephone number

Social Security or ID number (please specify number and type)

3. Tax Years/Periods. Please specify the tax year/periods during which the Signator is authorized, pursuant to A.R.S. § 42-

2003(A) to receive and discuss confidential information.

______________________________________________________________________________________________________

4. Signature. I hereby certify to the Arizona Department of Revenue that I am authorized to receive and discuss any and all

confidential information concerning the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s),

and/or individual(s) pursuant to A.R.S. § 42-2003(A). 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

Title

Print name

ADOR 03-0031 (4/00)

Form 285c - Disclosure Certification Form - Arizona Department Of Revenue