Washington Department of Revenue Tax Power of Attorney Form
In the State of Washington, should a resident hire a professional to file for her/his taxes, said resident must execute this form. Usually, the people hired for this purpose are accountants.Download
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CONFIDENTIAL TAX INFORMATION AUTHORIZATION Attention: Fax: Tax information is confidential and cannot be shared with anyone without the business/employer’s express permission. By completing this form, you are authorizing the agency to share your confidential tax information with the person(s) you name below . This is not a Power of Attorney form; it does not authorize parties to represent you by speaking on your behalf. Please fill in all parts of this form, carefully describing the specific information you want the agency to share and the periods covered by this authorization. This request may cover all confidential tax information or it may be lim ited to certain information and/or periods of time. Please read instructions on Page 2 . NOTE: This form will remain in effect unt il cancelled or replaced. Please refer to the Instructions on Page 2, Part 4. 1. EFFECTIVE DATE OF THIS AUTHORIZATION: 2. Enter UBI No. (use ES reference number for Employment Security) 3. Name of business/employer giving the selected agency authorization to share confidential tax information. Business/employer name(s) and mailing address: Telephone: Fax: E-mail: (optional) FEIN No: (optional) Check if new: Address Phone No. 4. Person, company, or firm with whom your confidential information can be shared. Name and mailing address: UBI/TIN/EIN: Telephone: Fax: E-mail: (optional) Check if: New and cancels any current Authorization Adds an additional person or company to current Authorization on file Note: This does not change the official mailing address for sending information to the business/employer. 5. Information to be shared (please describe or state “All”) 6. Year(s) or filing period(s) (be specific or state “All”) 7. Signature of person giving authorization (see instruction) I declare, under penalty of perjury, that I am authorized to sign this form. I am listed as the real property owner or as the b usiness owner, partner, corporate officer, or LLC member or manager in official records held by Washington State, or I have attached documentation (e.g., power of attorney, annual report, executor) that grants me the authority to sign. x Print Name Title (if applicable) Please Print x Signature x Dated City and State in Which Signed 8. Make a copy of this form for your files. Fax or mail original form to each agency as needed. Washington State Department of Revenue Taxpayer Services PO Box 47478 Olympia, WA 98504-7478 FAX: (360) 705-6733 Washington State Employment Security Department PO Box 9046 Olympia, WA , 98507-9046 FAX: (360) 902-9264 Washington State Department of Labor & Industries PO Box 44140 Olympia, WA 98504-4140 FAX: (360) 902-4729 Scanned copy: [email protected] For tax assistance or to request this document in an alte rnate format, visit http://dor.wa.gov or call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711. REV 27 0053e (1/30/13) EXC/TIA 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 y ou designate to inspect and/or receive your confidential tax information for the specified type and for th e 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 Authoriza tion 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 mailin g 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 i ndicates you are authorized to give the Agency this permission (e.g. corporate minutes, annual report, le tter of delegation, job description, certain in-person contact, guardian, executor, receiver, administrator, etc.). If your doc umentation 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 y our 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 (1/30/13)
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