Form Rev 27 0053e - Confidential Tax Information Authorization

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EXC/TIA
CONFIDENTIAL TAX INFORMATION AUTHORIZATION
Attention:
Fax:
Tax information is confidential and cannot be shared with anyone without the business/employer’s express permission. By completing
this form, you are authorizing the agency to share your confidential tax information with the person(s) you name below. This is not a
Power of Attorney form; it does not authorize parties to represent you by speaking on your behalf. Please fill in all parts of this form,
carefully describing the specific information you want the agency to share and the periods covered by this authorization. This request may
cover all confidential tax information or it may be limited to certain information and/or periods of time. Please read instructions on
Page 2.
NOTE: This form will remain in effect until cancelled or replaced. Please refer to the Instructions on Page 2, Part 4.
1. EFFECTIVE DATE OF THIS AUTHORIZATION:
2. Enter UBI No. (use ES reference number for Employment Security)
3. Name of business/employer giving the selected agency authorization to share confidential tax information.
Business/employer name(s) and mailing address:
Telephone:
Fax:
E-mail: (optional)
FEIN No: (optional)
Check if new:
Address
Phone No.
4. Person, company, or firm with whom your confidential information can be shared.
Name and mailing address:
UBI/TIN/EIN:
Telephone:
Fax:
E-mail: (optional)
Check if:
New and cancels any current Authorization
Adds an additional person or company to
current Authorization on file
Note: This does not change the official mailing address for sending information to the business/employer.
5. Information to be shared (please describe or state “All”)
6. Year(s) or filing period(s) (be specific or state “All”)
7. Signature of person giving authorization (see instruction)
I declare that I am authorized to execute this form on behalf of the business/employer for the information and periods stated above. I
am listed in official records held by Washington Secretary of State or Department of Licensing as the owner, partner, corporate
officer, LLC member or manager. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is
true and correct.
x
Print Name
Title (if applicable) Please Print
x
Signature
x
Dated
City and State in Which Signed
8. Make a copy of this form for your files. Fax or mail original form to each agency as needed.
Washington State
Washington State
Washington State
Department of Revenue
Employment Security Department
Department of Labor & Industries
Taxpayer Services
PO Box 44140
PO Box 47478
PO Box 9046
Olympia, WA 98504-4140
Olympia, WA 98504-7478
Olympia, WA , 98507-9046
FAX: (360) 902-4729
FAX: (360) 705-6733
FAX: (360) 902-9264
Scanned copy:
estechsupport@lni.wa.gov
To request this document in an alternate format, call 1-800-647-7706. Teletype (TTY) users may call (360) 705-6718.
REV 27 0053e (9/12/11)
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