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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
Name of Spouse, Fiduciary or Personal Representative (if applicable)
Federal Identification Number*
Spouse's Federal Identification Number
FORM 500 - AUTHORIZATION TO DISCLOSE TAX
INFORMATION & DESIGNATION OF REPRESENTATIVE
OFFICE OF NORTH DAKOTA STATE TAX COMMISSIONER
Do Not Com
lete if Checkin
Box D Below.
Name of Individual (or Firm)
E-mail AddressFax No.
Check the a
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
nated individual or firm with res
ect to the followin
Type of TaxTax Year or PeriodForm Number
Designation of Representative.
The Tax Commissioner is notified that the above-designated individual or firm has been authorized
resent the above-named tax
before the Office of State Tax Commissioner with res
ect to the followin
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.
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.
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.
nature of Tax
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
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