Form 4300 - Limited Power Of Attorney Borrower'S Authorization For Disclosure Of Information

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Michigan Department of Treasury
4300 (Rev. 5-05)
Limited Power of Attorney
Borrower's Authorization for Disclosure of Information
PART 1: GENERAL INFORMATION
Name of Person Authorizing Disclosure
If Business Partnership, Enter Additional Name
Address of Person Authorizing Disclosure
Business Address
Treasury Account Number
PART 2: EFFECTIVE DATES.
Up to four months from the date signed.
From
To
PART 3: AUTHORIZATION
The undersigned authorizes the Michigan Department of Treasury to release any and all information, including pay off amounts for
settlement, to ________________________ regarding any outstanding lien or debt obligations due by the undersigned. I / We do
not authorize any signature power to ____________________________.
Authorized Signature
Social Security Number
Date
Authorized Signature
Social Security Number
Date
Representatives Name
Telephone Number

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