Form Liq-Auth - Liquor Division Authorization To Disclose Tax Information
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3MONTANA
LIQ-AUTH
CLEAR FORM
Rev 03 13
Liquor Division
Authorization to Disclose Tax Information
Note: Each individual, partner, member, shareholder and/or entity must each complete a separate authorization form.
1. Taxpayer Information
Social Security Number(s)
Name of Taxpayer(s)/Applicant(s)/Licensee(s)
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-
-
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Liquor License Number
FEIN
-
Trade Name of Premises
Address
City
State
Zip Code
Telephone Number
Fax Number
Email Address
2. Authorization of Representative
Name of Representative
Name of Firm (if applicable)
Liquor Division Specialist
Montana Department of Revenue
Address
2517 Airport Road
City
State
Zip Code
Helena
Montana
59601
Telephone Number
Fax Number
(406) 444-0713
(406) 444-0722
3. Purpose of this Form
This form authorizes the liquor division specialist(s) to acquire confi dential taxpayer information from the Business and
Income Taxes Division for the named taxpayer(s) on this form.
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Parent category: Financial