Confidential Tax Information Authorization (Page 2 of 2) in pdf

Instructions for Completing the Confidential Tax Information Authorization

The Confidential Tax Information Authorization form (Authorization) grants the Department of Revenue (DOR),

Department of Labor and Industries (L&I), and Employment Security Department (ESD) permission to disclose to any

individual, corporation, firm, organization, or partnership you designate to inspect and/or receive your confidential tax

information for the specified type and for the year(s) or period(s) you list on the form. Note: This is not a Power of Attorney

form; it does not authorize parties to represent you by speaking on your behalf. Please read the instructions that follow.

PLEASE PRINT OR TYPE

If you were asked to send this document to a specific department employee enter the person’s name on the Attention line at

the top of the document along with his or her fax number. Otherwise, see instructions Part 8. A copy needs to be sent to each

agency as needed.

Part 1

Enter the date you want this authorization to begin. Normally this will be the current date.

Part 2

Enter UBI number or ES reference number.

Part 3

Provide complete information about the person that is granting authorization for disclosure of their confidential tax

information. This must include the following information or the Authorization cannot be processed:



Legal name of the person (eg. Owner name/partnership name/corporate name/limited liability company (LLC) name

etc).



Mailing address of the person.



Contact telephone number for the person (including fax number, e-mail address, and FEIN if available).



Indicate if either the address or telephone number are new to the account.

Part 4

Provide complete information regarding the person or company to whom the information is to be disclosed. This must

include the following information or the Authorization cannot be processed:



Name of the person, company, or firm to whom the information can be released.



Full mailing address of the person, company, or firm.



Contact telephone number of the person, company, or firm (including fax number and e-mail address if available).



Check the applicable box * indicating whether this Authorization is new or replaces current Authorization(s) on file,

or adds an additional person or company to the current Authorization on file.

(*Checking the new box will cancel previous Authorization on file).

Note: This does not change the official mailing address for sending information to employer.

To only cancel an existing Authorization on your account: Complete Parts 1, 2, 3, 4 and 7. In Part 4 write “Cancel

Previous Authorizations” in the name and address box.

Part 5

Indicate the information to be released to the person or company. You can choose to be very specific, limiting the

information to be disclosed, or you can indicate “All” to indicate no limitations to the information to be disclosed.

Part 6

Indicate the year(s) or filing period(s) for the information that you wish to be disclosed to the person or company, or state

“All” to indicate that there are no limitations.

Part 7

To complete this section, you must be an authorized signer. Authorized signers are generally the business owner, a partner,

corporate officer, or LLC member listed in Washington State records. If you cannot be verified by the Agency as an

authorized signer, it is your responsibility to provide supporting documentation that indicates you are authorized to give the

Agency this permission (e.g. corporate minutes, annual report, letter of delegation, job description, certain in-person contact,

guardian, executor, receiver, administrator, etc.). If your documentation cannot be verified, your request will not be allowed

and you will be notified by the Agency.

Part 8

Keep a copy of this completed form for your files. Unless instructed otherwise, send a copy of this form to each agency as

needed, using the fax numbers or addresses on the front of this form.

REV 27 0053e (09/13/13)

Confidential Tax Information Authorization Page 2

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