OTC Form
Oklahoma Tax Commission
A-100
Disclosure of Tax Information Authorization
Revised 7-2012
• Do not sign this form unless all applicable lines have been completed.
1. Taxpayer Information.
Taxpayer(s) must sign and date this form in Section 5.
Company or Individual Name(s) and Address
Social Security Number(s)
Employer Identification Number
Daytime Telephone Number
(
)
2. Appointee.
If you wish to name more than one appointee, check this box and attach a list to this form.
Name and Address
Telephone Number
(
)
Fax Number
(
)
3. Tax Matters.
The appointee is authorized to inspect and/or receive confidential tax information in any office of
the Oklahoma Tax Commission for the tax matters listed below.
(A)
(B)
(C)
(D)
Tax Type
Tax Form Number
Year(s) or Period(s)
Special Tax Matters
4. Disclose Tax Information.
Pursuant to the provisions of Section 205 c. (17) or (24) of the Oklahoma Uniform Tax Procedure Code (68 O.S.),
I request information relating to any liabilities, assessments, or warrants of the business identified above which
have not been filed or recorded, established, or become final and which relate specifically to my business
activities to be released to persons indictated above in Section 2.
Check the appropriate box:
Information is being requested for the prospective purchase of an existing business
(Title 68, Section 205.24).
(A)
Information is being requested for waiver of confidentiality
(Title 68, Section 205(c)17).
(B)
5. Signature of Taxpayer(s). See Instructions.
I attest that I have the authority to authorize the disclosure of any and all information in the files and records of the
Oklahoma Tax Commission pertaining to said business to the extent necessary.
If not signed and dated, this Tax Information Authorization will not be processed.
Taxpayer Signature
Date
Taxpayer Signature
Date
Title (if applicable) - Print Name
Title (if applicable) - Print Name
Mail To: Oklahoma Tax Commission, Post Office Box 26800, Oklahoma City, OK 73126-0800
Questions Call: (405) 521-3160