Supplemental Power Of Attorney - State Of Arizona - Office Of Administrative Hearings

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State of Arizona
Offi ce of Administrative Hearings
Supplemental Power of Attorney
Purpose of Form The Department of Revenue has transferred a contested matter to the Offi ce of Administrative Hearings
for a hearing. The Arizona statutes require written authorization before the Offi ce of Administrative Hearings can disclose
confi dential tax information to a taxpayer’s representative. This supplemental power of attorney form must be fi lled out by
the appointed representative and fi led with the Offi ce of Administrative Hearings in order that the Offi ce may deal with the
appointed representative in the matter(s) transferred to the Offi ce by the Department of Revenue.
Authority Granted This supplemental power of Attorney authorizes the individuals named herein to receive and inspect
confi dential tax information and to perform any and all acts the taxpayer(s) can perform with respect to these matters in
dealing with the Offi ce of Administrative Hearings.
1. Taxpayer Information
2. Applicable Identifi cation Number
Daytime telephone number
Arizona transaction privilege tax number
Taxpayer name(s)
(
)
Federal employer identifi cation number
Address
Social security number
City
State
ZIP code
3. Representative(s)
Name and address
ID number
Telephone number
(
)
Fax number
(
)
Name and address
ID number
Telephone number
(
)
Fax number
(
)
4. Tax Matters
Tax type
Entity/Type of return
Case Number
Transaction
Sole Proprietorship
Partnership
Privilege Tax
Corporation
Use
Sole Proprietorship
Partnership
Corporation
Other
(Specify Tax
Type)
ADOR 01-5414 (3/03)

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