Form Rd 1062 - Disclosure Authorization Form
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RD 1062
Mailing Address:
Georgia Department of Revenue
(Revised 8/2011)
Georgia Department of Revenue
PO Box 49708
Email: taxadv@dor.ga.gov
Atlanta,GA 30359-0708
Fax: (404) 417-6651
Disclosure Authorization Form
Print or Type
Enter only those that apply
1. Taxpayer Information
Federal Employer ID No.
Taxpayer(s) name(s) and address
Social Security No.
Georgia State Tax ID No.
Georgia Sales Tax Registration No.
Georgia Withholding Tax No.
Daytime Telephone Number
Provide one of the following identification numbers
2. Appointee Information
State and State Attorney Bar Number
Appointee name and address
Social Security or other identification number
(for other ID provide number and type)
State and Certified Public Accountant Number
Daytime Telephone Number
3. Tax Matters.
The appointee is authorized to receive confidential information for the tax matter listed below:
Tax Type
[ ]
Year(s) or Period (s)
Personal Income Tax.......................................................
Sales and Use Tax ..........................................................
Corporate Income Tax.....................................................
Withholding Tax...............................................................
Other (specify)
4. Revocation of Earlier Authorization(s).
This disclosure authorization form does not revoke any prior
authorization forms on file with the Department unless the following box is checked:
If the box is checked,
the revocation will be effective as to all earlier authorizations on file with the Department of Revenue except
(please specify):
I hereby certify that the Georgia Department of Revenue is authorized to
5. Signature of or for the Taxpayer.
disclose and/or discuss confidential information or records concerning the undersigned taxpayer to the appointee
named above for the tax type(s) and period(s) named above. If signed by a corporate officer, member, partner,
trustee or executor/executrix, I certify that I have the authority to execute this authorization form on behalf of the
taxpayer. I understand that to willfully prepare or present a document that is fraudulent or false is a misdemeanor
under O.C.G.A. § 48-1-6.
Signature:
Date:
Print Name:
Title (if applicable):
The person signing as or for the taxpayer appeared this day before a notary public and acknowledged this disclosure
authorization form as a voluntary act or deed.
Signature of Notary
Date
NOTARY SEAL
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