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North Dakota Tax Power of Attorney Form


North Dakota Tax Power of Attorney Form
North Dakota Tax Power of Attorney Form
Tax
p
a
y
er Information
This authorization to disclose tax information or a designation of representative does not cover the routine mailing of tax forms, refund checks,
original notices (e.g, a Notice of Determination), or other original written communications.
Name of Individual, Estate, Trust, Partnership, Corporation, LLP, or LLC
Street Address
Name of Spouse, Fiduciary or Personal Representative (if applicable)
Telephone No.
Telephone No.
Federal Identification Number*
Spouse's Federal Identification Number
City
State
Zip Code
FORM 500 - AUTHORIZATION TO DISCLOSE TAX
INFORMATION & DESIGNATION OF REPRESENTATIVE
OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER
SFN 28258
(
12-2013
)
Desi
g
nated Individual
(
or Firm
)
(
Do Not Com
p
lete if Checkin
g
Box D Below.
)
Name of Individual (or Firm)
Tele
p
hone No.
E-mail AddressFax No.
Check the a
pp
ro
p
riate box
(
es
)
:
A. Authorization To Disclose Tax Information. The Tax Commissioner is authorized to disclose confidential tax information on file
with the Office of State Tax Commissioner to the above-desi
g
nated individual or firm with res
p
ect to the followin
g
matters:
Type of Tax Tax Year or PeriodForm Number
B.
Designation of Representative.
The Tax Commissioner is notified that the above-designated individual or firm has been authorized
to re
p
resent the above-named tax
p
a
y
er
(
s
)
before the Office of State Tax Commissioner with res
p
ect to the followin
g
matters:
Type of Tax
Tax Year or PeriodForm Number
This designation of representative also authorizes the Tax Commissioner to disclose confidential tax information on file with the Office of
State Tax Commissioner to the representative. The representative is authorized to perform all acts that the taxpayer can perform except
that only an individual admitted and licensed to practice law in North Dakota may sign a complaint, represent the taxpayer in a formal
administrative review under North Dakota Century Code ch. 28-32, or represent the taxpayer in any court proceeding.
C.
Authorization To Disclose Tax Information Using Facsimile or E-mail.
The Tax Commissioner is authorized to use facsimile
or e-mail, or both, to disclose confidential tax information on file with the Office of State Tax Commissioner to the above-designated
individual or firm with respect to the above-identified matters.
D.
Revocation.
The Tax Commissioner is notified that all authorizations and designations previously made by the above-named taxpayer(s)
are revoked, and that no new authorization or designation is being made at this time. (If this box is checked, Do Not check Box A, Box B,
or Box C.)
This authorization to disclose tax information or a designation of representative takes effect upon receipt by the Office of State Tax Commissioner
and remains in effect until revoked by the taxpayer.
Si
g
nature of Tax
p
a
y
er
(
s
)
If signed by a corporate officer, partner, governor, manager, or fiduciary on behalf of taxpayer, I certify I have authority to sign this form on behalf
of the taxpayer.
Signature
Date
For Office Use Only
Printed Signature
Printed Spouse's Signature
Signature of Spouse, if applicable
Date
Street Address City State Zip Code
Federal Identification Number
Title
North Dakota Tax Power of Attorney Form
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