Form 285a - Audit Disclosure Authorization Form printable pdf download

Audit Disclosure Authorization Form

ARIZONA FORM

285A

RIZONA

EPARTMENT OF

EVENUE

Effective February 29, 2000

This form authorizes the Department to disclose conﬁ dential information of the taxpayer(s) named below to the appointee(s) named below

for the tax type(s) speciﬁ ed below. This form is NOT A POWER OF ATTORNEY and DOES NOT grant the appointee(s) any powers of

representation.

1. TAXPAYER INFORMATION - Please print or type.

Enter only those that apply:

Taxpayer name(s)

Federal Employer Identiﬁ cation Number

Present address - number and street, rural route, apartment/suite no.

Arizona Withholding Number

City, town or post ofﬁ ce

State

Zip Code

Arizona Transaction Privilege Tax License Number

Daytime telephone number

Social Security Numbers

(

)

2. APPOINTEE INFORMATION

APPOINTEE (if applicable)

Name

Address (if different from Taxpayer’s address above)

City, town or post ofﬁ ce

State

Zip Code

City, town or post ofﬁ ce

State

Zip Code

Daytime telephone number

(

)

(

)

Social Security or ID Number (please specify type)

3. TAX MATTERS. The appointee is authorized to receive and discuss conﬁ dential 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

! Withholding Tax

! Limited Liability Company

! Limited Liability Partnership

! Estate

! Other (specify tax type):

Specify type of return(s)/ownership:

____________________

4. REVOCATION OF EARLIER AUTHORIZATION(S). If you wish to revoke any earlier authorizations or Powers of Attorney on ﬁ le

with the Arizona Department of Revenue, please check this box.............................................................................................................

The revocation will be effective as to ALL earlier authorizations and Powers of Attorney (even those relating to a different tax type)

on ﬁ le with the Department of Revenue except those speciﬁ ed (please specify): _________________________________________

_________________________________________________________________________________________________________

5. SIGNATURE OF OR FOR TAXPAYER. I hereby certify that the Arizona Department of Revenue is authorized to release any and all conﬁ dential

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

______________________________________________________________

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PRINT NAME

______________________________________________________________

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