Form Ador 91-5419 - Arizona Tax Amnesty Application - Income, Withholding, And Luxury Taxes Page 2

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Arizona Tax Amnesty Tax Application
Income • Withholding • Luxury
Page 2 of 2
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PAID PREPARER’S SIGNATURE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PAID PREPARER’S TIN
DATE
PAID PREPARER’S ADDRESS
Mail to Arizona Department of Revenue, P.O. Box 52153, Phoenix, AZ 85072-2153
ADOR 91-5419 (7/03)

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