Form 21-003 - Waiver And Authorization To Release Confidential Taxpayer Information (Page 2 of 2) in pdf

Form 21-003 - Waiver And Authorization To Release Confidential Taxpayer Information Page 2

INSTRUCTIONS FOR SIGNING

This waiver and authorization must be signed by the bonded principal named above. In the case of an individual

bonded principal, this form must be signed by that individual. In the case if a partnership, this form must be signed by any

member of the partnership during any part of the period covered by referenced bond. In the case of a member managed

limited liability company, this form must be signed by any person who was a member if the limited liability company during

any part of the period covered by the bond. In the case of a manager managed limited liability company, this form must be

signed by any manager of the limited liability company. In the case of a corporation, th

is form must be signed by a principal

officer of the corporation and attested to by the corporation’s secretary or other officer.

This the ______ day of ___________, 201__.

Signature

Capacity

ATTEST (In the case of corporations)

By:

Title:

ACKNOWLEDGEMENT

State of

County

Personally appeared before me, the undersigned authority in and for the said county and state, on this _______ day

of ___________________, 201__, within my jurisdiction, the within named ______________________________________

who acknowledged that he/she executed the above and foregoing instrument after having been duly authorized so to do.

Notary Public

y Commission Expires: __________________

(SEAL)

Form 21-003 - Waiver And Authorization To Release Confidential Taxpayer Information Page 2