Form Dr 9596 - Gaming License Renewal Application Form Page 4
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7Colorado Division of Gaming
AUTHORIZATION FOR DISCLOSURE
FOR COLORADO DEPARTMENT OF REVENUE
Printed Full Legal Name (Last, First, Middle)
Social Security Number
Printed Full Legal Name and Social Secur ity Number of Person(s) You Have Filed a Joint State Tax Return Within Past 5 Years
I/We do hereby appoint a duly author ized agent of the Color ado Division of Gaming as m y/our
lawful attorney in fact to request, review, receive, copy and use for licensing or regulatory purposes
confidential tax information and records from the Colorado Department of Revenue relating to me/
us. This power of attorney ends twenty-four (24) months from the date of execution.
Signature of Applicant (Must be signed in front of tw o witnesses)
Dated this __________ day of _____________________ 20 _______ at _______________ , _______________________________ , __________
(day)
(month)
(year)
(time)
(city)
(state)
Witness 1 Signature
Witness 2 Signature
IF YOU FILED JOINTLY, THE JOINT ACCOUNT HOLDER MUST SIGN BELOW
Signature of Joint Account Holder (Must be signed in front of tw o witnesses)
Dated this __________ day of _____________________ 20 _______ at _______________ , _______________________________ , __________
(day)
(month)
(year)
(time)
(city)
(state)
Witness 1 Signature
Witness 2 Signature
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