Form 500 - Authorization To Disclose Tax Information And Designation Of Representative Page 2
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1
2Instructions For Form 500
General Information
Form 500 may be used by a taxpayer to Either:
A disclosure authorized by this form may take place by
telephone, letter, facsimile, or e-mail (if that information is
1.
Authorize the Offi ce of State Tax Commissioner to disclose
provided and Box C is also checked).
confi dential tax information with respect to the taxpayer
to another individual or fi rm not otherwise entitled to the
To change a Form 500 previously fi led, a taxpayer must complete
information; or
and fi le a new Form 500. The fi ling of a new Form 500 will
automatically revoke all authorizations and designations
2. Designate another individual or fi rm to represent or act on
previously made.
behalf of the taxpayer and authorize the Offi ce of State Tax
Commissioner to disclose confi dential tax information to the
Mail the completed Form 500 to: Offi ce of State Tax
designated representative.
Commissioner, 600 E. Boulevard Ave., Dept. 127, Bismarck, ND
58505-0599.
Completing Form 500
Taxpayer Information
Box C - Check this box to authorize the Offi ce of State Tax
For an individual - Enter the individual’s name, telephone
number, social security number, and mailing address.
Commissioner to use facsimile or e-mail to disclose
confi dential tax information to the designated individual
For a corporation, partnership, LLP, or LLC - Enter the name,
or fi rm.
telephone number, federal identifi cation number, and business
address.
Box D - Check this box if Form 500 is being fi led to revoke all
previously made authorization(s).
For a trust - Enter the name, telephone number, and federal
Note:
If a separate sheet is being attached to identify additional
identifi cation number of the trust, and the name and address of
the fi duciary.
designated individuals or fi rms, indicate the authority
being given by entering “Box A” or “Box B,” and
For an estate - Enter the name and social security number or
“Box C”, if desired, next to each one listed.
federal identifi cation number of the decedent, and the name,
telephone number, and address of the decedent’s personal
Type of Tax, Form Number, Tax Year or Period
representative or fi duciary for the estate.
If limiting authorization or designation to a certain tax type, form,
or taxable year or period, enter the type of tax (e.g., Individual
Income Tax or Corporation Income Tax), the form number (e.g.,
Designated Individual or Firm
Enter the name, title, telephone number, social security number
Form ND-1 of Form 40), and tax year(s) or period(s) (e.g., 2002
or federal identifi cation number, and mailing address of the
or Tax period ending June 30, 2002). If more space is needed,
designated individual or fi rm. To authorize the disclosure of
attach an additional sheet.
confi dential tax information by facsimile or e-mail, enter the
facsimile number or e-mail address, or both, and check Box C
Signature of Taxpayer(s)
on the form. If designating more than one individual or fi rm,
For a partnership - One of the general partners must sign.
identify on a separate sheet and attach it to Form 500.
For a corporation - An offi cer having authority to bind the
Which Box To Check
corporation must sign.
Box A - Check this box if Form 500 is being fi led to Only
authorize the Offi ce of State Tax Commissioner to
For an LLC or LLP - A governor, manager, responsible member
or partner must sign.
disclose confi dential tax information to an individual or
fi rm other than the taxpayer.
For an estate, trust, or any other situation where there is a
Box B - Check this box if Form 500 is being fi led to designate
fi duciary relationship - The personal representative, trustee,
guardian, conservator, or other fi duciary must sign.
another individual or fi rm to represent or act on
behalf of the taxpayer. Checking this box also
authorizes the Offi ce of State Tax Commissioner to
disclose confi dential tax information to the designated
representative.
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