Form 150-800-005 - Authorization To Represent Taxpayer And/or Disclose Information printable pdf download

AUTHORIZATION TO REPRESENT TAXPAYER

FOR OFFICE USE ONLY

O R E G O N

AND/OR DISCLOSE INFORMATION

Date Received

D E PA R T M E N T

O F R E V E N U E

Taxpayer Name(s)

Social Security No. or Other Identifying No.

Taxpayer Street Address

City

State

ZIP Code

Payment/Collection issue

No return filed

Appeal pending

Other:

Tax/Audit issue

Check the tax program(s) this authorization applies to:

Personal Income Tax

Partnership/LLP

Payroll/Withholding Tax

Timber Tax

(See No. 5 on the back)

Elderly Rental Assistance

Other Agency Accounts

Tri-Met Transit Tax

Limited Liability Co.–filed as:

Corporation Tax

Lane Transit Dist. Tax

Other:

Partnership

Fiduciary Income Tax

Property Tax

Corporation

For tax year(s) _________________________________________ I HEREBY AUTHORIZE: (see authorization requirements on back)

Name

Telephone Number

FAX Number

(

)

(

)

Mailing Address

City

State

ZIP Code

Check all that apply:

To provide to and/or receive from the Oregon Department of Revenue, information relating to the taxpayer(s)’ liability for the

tax(es), interest, penalty, or other charge for the tax year(s) indicated above. Information does not include service of original

notices of deficiency, assessment, or refund adjustments.

To represent the taxpayer before the Oregon Department of Revenue in any matter relating to the taxpayer(s)’ liability for the

tax(es), interest, penalty, or other charge for the year(s) indicated above. This representative has full power to do all things

necessary as fully and with as binding effect as the taxpayer(s) might do, including but not limited to providing information,

preparing, signing, executing, and filing reports and returns, inspecting reports or returns on file, executing extensions of statutes

of limitations, and executing closing agreements.

To designate a tax matters partner (see OAR 150-305.242(2) and (5)). Partnership name: ________________________________

All authorizations for this purpose that were previously filed or executed by the taxpayer(s) for the tax years referenced, are still valid.

SIGNATURE OF OR FOR TAXPAYER(S)

As a corporate officer, partner, fiduciary, transferee, or other qualified person signing on behalf of the taxpayer, I certify that I have the

authority to execute this authorization on behalf of the taxpayer.

Telephone Number

Date

Signature

Title (if applicable)

(

)

City

State

Street Address

ZIP Code

Telephone Number

Date

Signature

Title (if applicable)

(

)

City

State

Street Address

ZIP Code

Please complete the following, if known (for routing purposes only):

Revenue employee:

Send to: Oregon Department of Revenue

955 Center St NE

Division/Section:

Salem OR 97310-2501

Employee Phone No.:

Employee FAX No.:

Authorization requirements are on the back

150-800-005 (Rev. 11-98)

Form 150-800-005 - Authorization To Represent Taxpayer And/or Disclose Information

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