Arizona Form 285b - Disclosure Authorization Form
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1ARIZONA FORM
Disclosure Authorization Form
285B
ARIZONA DEPARTMENT OF REVENUE
This form authorizes the Department to release confi dential information of the taxpayer(s) named below to the appointee(s) named below
for the tax type(s) specifi ed below. This form is NOT A POWER OF ATTORNEY and DOES NOT grant the appointee(s) any powers of
representation.
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 Identifi cation No.
City, Town or Post Offi ce
State ZIP Code
Daytime Phone (with area code)
AZ Transaction Privilege Tax License No.
2. APPOINTEE INFORMATION
2nd APPOINTEE INFORMATION (if applicable)
Name
Name
Address (if different from taxpayer’s address above)
Apt./Suite Address (if different from taxpayer’s address above)
Apt./Suite
City, Town or Post Offi ce
State ZIP Code
City, Town or Post Offi ce
State ZIP Code
Daytime Telephone Number (with area code)
Daytime Telephone Number (with area code)
Social Security or Other ID No.
Type
Social Security or Other ID No.
Type
|
|
3. TAX MATTERS: The appointee is authorized to receive and discuss confi dential information for the tax matters listed below.
TAX TYPE
YEAR(S) OR PERIOD(S)
TYPE OF RETURN/OWNERSHIP
Income Tax
Individual Joint Return
Individual Single Return
Corporation
Partnership
Fiduciary-Trust
Fiduciary-Estate
Transaction Privilege
Individual/Sole Proprietorship
Partnership
Corporation
Trust
and Use Tax
Limited Liability Company
Limited Liability Partnership
Estate
Withholding Tax
Other (specify tax type):
Specify type of return(s)/ownership:
4. REVOCATION OF EARLIER AUTHORIZATION(S)
This Disclosure Authorization Form does not revoke any prior Power of Attorney or other authorization forms on fi le with the
Department.
5. SIGNATURE OF OR FOR TAXPAYER
I hereby certify that the Arizona Department of Revenue is authorized to release any and all confi dential information concerning the
above-mentioned Taxpayer. By signing this form, I certify that I have the authority, within the meaning of A.R.S. §42-2003(A), to
execute this authorization form on behalf of the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s),
and/or individual(s). 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).
________________________________________________
_______________________________________________
SIGNATURE
DATE
SIGNATURE
DATE
________________________________________________
_______________________________________________
PRINT NAME
PRINT NAME
________________________________________________
_______________________________________________
TITLE
TITLE
ADOR 10955 (5/12)
Print Form
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