Form 500 - Authorization To Disclose Tax Information And Designation Of Representative - North Dakota Office Of State Tax Commissioner
Download a blank fillable Form 500 - Authorization To Disclose Tax Information And Designation Of Representative - North Dakota Office Of State Tax Commissioner in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 500 - Authorization To Disclose Tax Information And Designation Of Representative - North Dakota Office Of State Tax Commissioner with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Form
North Dakota Office of State Tax Commissioner
500
Authorization To Disclose Tax Information
And Designation of Representative
Taxpayer Information
Telephone No.
Soc. Sec. No. or FID No.
Name of Individual, Estate, Trust, Partnership, Corporation, LLP, or LLC
Name of Spouse, Fiduciary or Personal Representative (if applicable)
Telephone No.
Spouse's Soc. Sec. No.
Street Address
City
State
Zip Code
Designated Individual (or Firm) (Do Not Complete if Checking Box D Below.)
Name of Individual (or Firm)
Telephone No.
Soc. Sec. No. or FID No.
E-mail Address
Street Address
City
Fax No.
State
Zip Code
Check the appropriate box(es):
A. Authorization To Disclose Tax Information.
The Tax Commissioner is authorized to disclose confidential tax information on file
with the Office of State Tax Commissioner to the above-designated individual or firm with respect to the following matters:
Type of Tax
Form Number
Tax Year or Period
B. Designation of Representative.
The Tax Commissioner is notified that the above-designated individual or firm has been authorized
to represent the above-named taxpayer(s) before the Office of State Tax Commissioner with respect to the following matters:
Type of Tax
Form Number
Tax Year or Period
This designation of representative also authorizes the Tax Commissioner to disclose confidential tax information on file with the Office of
State Tax Commissioner to the representative. The representative is authorized to perform all acts that the taxpayer can perform except
that only an individual admitted and licensed to practice law in North Dakota may sign a complaint, represent the taxpayer in a formal
administrative review under North Dakota Century Code ch. 28-32, or represent the taxpayer in any court proceeding.
C. Authorization To Disclose Tax Information Using Facsimile or E-mail.
The Tax Commissioner is authorized to use facsimile
or e-mail, or both, to disclose confidential tax information on file with the Office of State Tax Commissioner to the above-designated
individual or firm with respect to the above-identified matters.
D. Revocation.
The Tax Commissioner is notified that all authorizations and designations previously made by the above-named taxpayer(s)
are revoked, and that no new authorization or designation is being made at this time. (If this box is checked, Do Not check Box A, Box B,
or Box C.)
This authorization to disclose tax information or a designation of representative does not cover the routine mailing of tax forms, refund checks,
original notices (e.g, a Notice of Determination), or other original written communications.
This authorization to disclose tax information or a designation of representative takes effect upon receipt by the Office of State Tax Commissioner
and remains in effect until revoked by the taxpayer.
Signature of Taxpayer(s)
If signed by a corporate officer, partner, governor, manager, or fiduciary on behalf of
taxpayer, I certify I have authority to sign this form on behalf of the taxpayer.
Signature
Date
For Office Use Only
Printed Signature
Title, if applicable
Date
Signature of Spouse, if applicable
Printed Spouse's Signature
(Rev. date 01/2004)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Authorization To Disclose Health Information And Other Records Hipaa Compliant Form - California
Legal
Form Atf F5030.6 - Authorization To Furnish Financial Information And Certificate Of Compliance
Legal
Related Categories
Parent category: Financial