ARIZONA FORM
Disclosure Certification Form
285C
ARIZONA DEPARTMENT OF REVENUE
This form should be used to certify to the Department that the person named below (“Signator”) is authorized,
pursuant to A.R.S. §42-2003(A), to receive and discuss confidential information of the taxpayer(s) named below or
to execute a power of attorney form for another person.
1. TAXPAYER INFORMATION: Please print or type.
Enter only those that apply:
Taxpayer Name
Social Security No.
Spouse’s Name (if applicable)
Spouse’s Social Security No.
Present Address - number and street, rural route
Apartment/Suite No.
Employer Identification No.
City, Town or Post Office
State ZIP Code
Daytime Phone (with area code)
AZ Transaction Privilege Tax License No.
2. SIGNATOR INFORMATION
You must provide an Identification Number:
Name
Social Security or Other ID No. Type
|
Business Address (if different from Taxpayer’s address above)
Apartment/Suite No. Daytime Phone Number (with area code)
City, Town or Post Office
State
ZIP Code
3. TAX YEARS / PERIODS
Please specify the tax years/periods during which the Signator is authorized, pursuant to A.R.S. §42-2003(A), to receive and
discuss confidential information or to execute a power of attorney form for another person:
4. CERTIFICATION
I hereby certify to the Arizona Department of Revenue that I am authorized to receive and discuss any and all confidential
information concerning the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s), and/
or individual(s) pursuant to A.R.S. §42-2003(A). I understand that to knowingly prepare or present a document which is
fraudulent or false is a class 5 felony pursuant to A.R.S. §42-1127(B)(2).
I hereby certify to the Arizona Department of Revenue that I am authorized to sign the Power of Attorney/Disclosure
Certification form on behalf of the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s),
and/or individual(s) pursuant to A.R.S. §42-2003(A). I understand that to knowingly prepare or present a document which is
fraudulent or false is a class 5 felony pursuant to A.R.S. §42-1127(B)(2).
5. SIGNATURE
SIGNATURE
DATE
PRINT NAME
TITLE
ADOR 10954 (5/12)
Print Form