Arizona Form 285a - Audit Disclosure Authorization Form
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1ARIZONA FORM
285A
Audit Disclosure Authorization Form
Effective February 29, 2000
ARIZONA DEPARTMENT OF REVENUE
1. TAXPAYER INFORMATION: Please print or type.
Enter only those that apply:
Taxpayer Name(s)
Employer Identification Number
Present Address - number and street, rural route
Apartment/Suite No.
Arizona Withholding Number
City, Town or Post Office
State
Zip Code
Arizona Transaction Privilege Tax License Number
Daytime Telephone Number (with area code)
Social Security Number(s)
2. APPOINTEE INFORMATION
2nd APPOINTEE INFORMATION (if applicable)
Name
Name
Address (if different from taxpayer’s address above) Apartment/Suite No. Address (if different from taxpayer’s address above) Apartment/Suite No.
City, Town or Post Office
State
Zip Code
City, Town or Post Office
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 confidential 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)
Check this box if you wish to revoke any earlier authorizations or Powers of Attorney on file with the Arizona Department of Revenue.
The revocation will be effective as to ALL earlier authorizations and Powers of Attorney (even those relating to a different tax
type) on file with the Department of Revenue except those specified (please specify):
5. SIGNATURE OF OR FOR TAXPAYER
I hereby certify that the Arizona Department of Revenue is authorized to release any and all confidential 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), estate(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 10953 (1/11)
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