Form Rev-467 - Authorization For Release Of Tax Records
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1
2REV-467 LE+ (09-12)
AUTHORIZATION
FOR RELEASE OF
BUREAU OF ADMINISTRATIVE SERVICES
TAX RECORDS
DIRECTOR’S OFFICE
12TH FL STRAWBERRY SQ
PLEASE PRINT OR TYPE
HARRISBURG PA 17128-1200
Pennsylvania tax records are confidential and may be released only to the taxpayer or pursuant to a release signed by the taxpayer.
Unauthorized disclosure of tax information is a criminal offense.
Completion of this form authorizes the PA Department of Revenue to release the tax return documents identified in Part ll.
Carefully read the instructions on the reverse and fill out the form completely.
START
PART I - DESIGNATION OF INDIVIDUAL TO RECEIVE TAX RECORDS
1.
Full Name of Designated Individual
Telephone No.
2.
Name of Individual, Firm or Agency
3.
Street Address
4.
City
State
ZIP Code
PART ll - TAX RECORDS TO BE RELEASED (See Instructions on reverse side.)
1
2
3
4
5
Taxpayer’s Name as Shown on Original Return
Tax ID No.
Tax
Record
Tax Period
6.
Current Street Address of Taxpayer
City
State
ZIP Code
7.
Street Address Used in Filing Returns
City
State
ZIP Code
PART III - CERTIFICATION
I certify that l:
am the individual whose tax records are to be released.
am a duly authorized corporate officer of the corporation for which tax records are to be released.
(Corporate Title)
am a general partner of the partnership for which tax records are to be released.
am empowered by a power of attorney on tax matters to request release of the tax records. (See instructions on reverse side.)
have been appointed as the executor or administrator of the will or estate of the deceased taxpayer whose tax records are to
be released. (See instructions on reverse side.)
PLEASE SIGN AFTER PRINTING
Signature
Date
MM/DD/YY
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