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ADOR 10952 (5/12)
General Disclosure/Representation Authorization Form
ARIZONA DEPARTMENT OF REVENUE
Effective July 3, 2003
Continues on Page 2 Î
1. TAXPAYER INFORMATION: Please print or type.
Enter only those that apply:
Taxpayer NameSocial Security No.
Spouse’s Name (if applicable)Spouse’s Social Security No.
Present Address - number and street, rural routeApartment/Suite No.Employer Identification No.
City, Town or Post OfficeStateZIP CodeDaytime Phone (with area code)AZ Transaction Privilege Tax License No.
2. APPOINTEE INFORMATION
Enter one of the following identification numbers:
NameState and State Bar No.
Present Address - number and street, rural routeApartment/Suite No.State and Certified Public Accountant No.
City, Town or Post OfficeStateZIP CodeInternal Revenue Service Enrolled Agent No.
Daytime Phone (with area code)Social Security or Other ID No. Type
3. TAX MATTERS: The appointee is authorized to receive confidential information for the tax matters listed below. By signing this form, I authorize
the Department to release confidential information of the taxpayer(s) named above to the appointee named above for the tax type and tax year(s)/
period(s) specified below. To grant additional powers, please see section 4. To grant a Power of Attorney, please skip section 4 and go to
TAX TYPEYEAR(S) OR PERIOD(S)TYPE OF RETURN/OWNERSHIP
Individual Joint Return
Individual Single Return
and Use Tax
Limited Liability Company
Limited Liability Partnership
Other (specify tax type):Specify type of return(s)/ownership:
4. ADDITIONAL AUTHORIZATION: Items 4a through 4h allow the taxpayer(s) to grant additional authorization to the appointee named
above. Please check the boxes accordingly. An additional authorization must be in accordance with Arizona Supreme Court Rule 31.
4a Appointee shall have the power to sign a statute of limitations waiver on Taxpayer’s behalf.
4b Appointee shall have the power to execute a protest of a deficiency assessment or a denied refund claim or to execute an
agreement on Taxpayer’s behalf.
4c Appointee shall have the power to request a formal hearing on Taxpayer’s behalf.
4d Appointee shall have the power to represent the taxpayer in any administrative tax proceeding.
4e Appointee shall have the power to execute a closing agreement on Taxpayer’s behalf.
4f Appointee shall have the power to represent the taxpayer in any collection matter including an Offer-In-Compromise.
4g Appointee shall have the authority to delegate to others any or all authority granted to appointee by this document.
4h Other (please specify):
5.POWER OF ATTORNEY: By checking the box on line 5, the taxpayer grants the above-named appointee a Power of Attorney to perform any and
all acts that the taxpayer can perform with regard to the above-mentioned tax matters and tax year(s) or period(s). This Power of Attorney includes,
but is not limited to, the powers listed in items 4a through 4h. The use of a Power of Attorney must be in accordance with Arizona Supreme Court
Rule 31. Please specify any limitation to the Power of Attorney:
6. REVOCATION OF EARLIER AUTHORIZATION(S): This authorization does not revoke any earlier authorizations or Powers of
Attorney on file with the Arizona Department of Revenue unless the revocation box to the left is checked. The revocation will
be effective as to all earlier authorizations and Powers of Attorney on file with the Arizona Department of Revenue except
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