Form 150-800-005 - Authorization To Represent Taxpayer And/or Disclose Information - Oregon Department Of Revenue
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1FOR OFFICE USE ONLY
O R E G O N
AUTHORIZATION TO REPRESENT TAXPAYER
Date Received
D E PA R T M E N T
AND/OR DISCLOSE INFORMATION
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 (5) on the back)
Elderly Rental Assistance
Tri-Met Transit Tax
Other Agency Accounts
Limited Liability Co.–filed as:
Corporation Tax
Lane Transit Dist. Tax
Other:
Partnership
Fiduciary Income Tax
Corporation
Property Tax
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 tax(es),
interest, penalty, or other charges 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 tax(es),
interest, penalty, or other charges for the tax 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.
SIGNATURES OF OR ON BEHALF OF TAXPAYER(S)
As a corporate officer, partner, fiduciary, transferee, or other qualified person signing on behalf of the taxpayer(s), I certify that I have
the authority to execute this authorization on behalf of the taxpayer(s). (If taxpayers filed jointly, both must sign.)
Signature
Title (if applicable)
Telephone Number
Date
(
)
X
Street Address
City
State
ZIP Code
Signature
Title (if applicable)
Telephone Number
Date
(
)
X
Street Address
City
State
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 97301-2555
Employee Telephone No.:
Employee Fax No.:
Authorization requirements are on the back
150-800-005 (Rev. 8-01) Web
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