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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

Extracted Text for Proper Search

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: estechsupport@lni.wa.gov	
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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