Arizona Form 821 - Withholding Tax Information Authorization
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1ARIZONA FORM
STATE OF ARIZONA • DEPARTMENT OF REVENUE
Withholding Tax Information Authorization
821
1. Taxpayer Information - Taxpayer must sign and date this form on line 5.
Taxpayer Name
Daytime Telephone Number
Employer Identifi cation Number (EIN)
(with area code)
Address (Number and street or PO Box)
City
State
Zip Code
2. Appointee Information
Name
Identifi cation Number
Address (Number and street or PO Box)
Telephone Number (with area code)
City
State
Zip Code
Fax Number (with area code)
3. Authorization
The appointee is authorized to inspect and/or receive confi dential Arizona withholding tax information for the following tax year(s) or period(s):
4. Retention/Revocation of Withholding Tax Information Authorization
This withholding tax information authorization automatically revokes all earlier withholding tax information authorization(s) on fi le with the
Arizona Department of Revenue for the same years or periods covered by this document. If you do not want to revoke a prior withholding tax
information authorization, check this box ..............................................................................................................................................
You must attach a copy of any withholding tax information authorization you want to remain in effect.
5. Signature of or for Taxpayer
I hereby certify that the Director of the Arizona Department of Revenue is authorized to release any and all Arizona withholding tax information
in department fi les concerning the undersigned taxpayer and relieve said Director, or department representative, of any liability whatsoever for
releasing such withholding tax information to the appointee specifi ed by this withholding tax information authorization. If signed by a corporate
offi cer or partner, I certify that I have the authority to execute this withholding tax information authorization on behalf of the taxpayer(s).
If this withholding tax information authorization is not signed, it will be returned.
Print Name
Print Name
Signature
Signature
Date
Date
Print
Arizona Department of Revenue, PO Box 29086, Phoenix AZ 85038-9086
Send Form to:
ADOR 10172 (12)
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