Form Ador 11156 - Memorandum Of Understanding - 2011
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1Fill in boxes 1 through 10.
In Box 1, enter the name of
Memorandum of Understanding
the company.
PURPOSE
The purpose of this Memorandum of Understanding (MOU) between the Arizona Department of Revenue (ADOR)
1
and
hereafter referred to as Payroll Service Company
(PSC), is to ensure that PSC has on file a signed authorization from each client that authorizes PSC to pay and
file withholding taxes to ADOR, and to receive tax account information from ADOR in order to resolve account
discrepancies. This MOU shall serve to permit PSC to resolve tax matters with ADOR on each client’s behalf.
State Information
State Name
Arizona
Agency Name
Department of Revenue
Address
1600 W Monroe St.
City, State, Zip
Phoenix, AZ 85007
Contact Name
Jeanette Maez
Phone
(602)716-6052
Fax
(602)542-2072
Payroll Service Company Information
2
Company Name
EIN
3
4
Address
City, State, Zip
6
7
5
Contact Name
Phone
Fax
A. Duties
Under this MOU, ADOR will disclose to PSC confidential information necessary to assist PSC with client
billing and general payroll tax account questions and validation in connection with the returns that PSC files
on its client’s behalf. PSC agrees to provide a copy of a client’s authorization, by mail or fax, within 24 hours
upon request. PSC will notify ADOR immediately if a client authorizes PSC to receive confidential
information on its client’s behalf or if a client withdraws its authorization.
B. Confidentiality
PSC agrees to restrict access to the information provided to specifically authorized personnel and to use the
information only to produce accurate and timely tax reports for each employer. PSC agrees to instruct
authorized personnel who have access to the data as to the confidentiality requirements for protecting the
data.
C. Security
PSC assumes responsibility for the information provided and will maintain appropriate computer system
security measures, which restrict access to system files, records, and databases to authorized persons.
D. Termination
ADOR may suspend its disclosure of confidential information immediately if it determines that PSC has
violated its obligations under this MOU, including failure to provide a copy of a requested authorization form,
unauthorized disclosure to third parties, or failure to secure confidential information. Either party may
terminate this MOU at any time by giving written notice to the other party at least sixty (60) calendar days
prior to the effective date of termination.
E. Amendments
No amendment to this MOU shall be effective unless it is in writing and signed by authorized representatives
of both parties.
APPROVALS
Jeanette Maez
Administrator
State Agency Representative Name
State Agency Authorized Signature
Title
Date
10
9
8
PSC Representative Name
PSC Authorized Signature
Title
Date
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