
This form authorizes the Department to release condential information of the taxpayer(s) named below to the appointee(s) named below
for the tax type(s) specied below. This form is NOT A POWER OF ATTORNEY and DOES NOT grant the appointee(s) any powers of
representation.
ADOR 10955 (8/18)
1. TAXPAYER INFORMATION: Please print or type. Enter only those that apply:
Taxpayer Name Social Security Number or ITIN
Spouse’s Name (if applicable) Spouse’s Social Security Number or ITIN
Current Address - number and street, rural route Apartment/Suite No. Employer Identification Number
City, Town or Post Office State ZIP Code Daytime Phone (with area code) AZ Transaction Privilege Tax License No.
2. APPOINTEE INFORMATION 2nd APPOINTEE INFORMATION (if applicable)
Name Name
Current Address (if different from taxpayer’s address above) Apt./Suite Current Address (if different from taxpayer’s address above) Apt./Suite
City, Town or Post Office State ZIP Code City, Town or Post Office State ZIP Code
Daytime Phone (with area code) Daytime Phone (with area code)
Social Security, ITIN, or Other ID No. Type
|
Social Security, ITIN, or Other ID No. Type
|
3. TAX MATTERS: The appointee is authorized to receive confidential information for the tax matters listed below.
TAX TYPE YEAR(S) OR PERIOD(S) TYPE OF RETURN/OWNERSHIP
Income Tax
Individual
Partnership
Corporation
Fiduciary-Estate/Trust
Transaction Privilege
and Use Tax
Individual/Sole Proprietorship
Limited Liability Company
Partnership
Corporation
Limited Liability Partnership
Trust
Estate
Withholding Tax
Other (e.g., Luxury Tax): Specify type of return(s)/ownership:
4. NO REVOCATION OF EARLIER AUTHORIZATION(S)
This Disclosure Authorization Form does not revoke any prior Power of Attorney or other authorization forms on file with the department.
5. SIGNATURE OF OR FOR TAXPAYER
I hereby certify that the Arizona Department of Revenue is authorized to release any and all condential information concerning
the Taxpayer(s). 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 Taxpayer(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).
By checking this box and signing below I certify under penalty of perjury that I am an ofcer of the above mentioned corporation(s)
and that I am a principal ofcer, as dened in A.R.S. §42-2003(A)(2).
________________________________________________ _______________________________________________
SIGNATURE DATE SIGNATURE DATE
________________________________________________ _______________________________________________
PRINT NAME PRINT NAME
________________________________________________ _______________________________________________
TITLE TITLE
Arizona Form
285B
Disclosure Authorization Form
You must sign this form in section 5