Main Navigation
Form 285-I Fillable Individual Income Tax Disclosure/Representation Authorization Form
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(Click down arrow; click to select option) (Click to clear form) Reset Form (Click to print form) Print Form (Click to select) Unchecked (Enter digits only without dashes) (Enter digits only; include area code) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 1 TAXPAYER INFORMATION: Please print or type 2 APPOINTEE INFORMATION 285 I 3 TAX MATTERS: 6 SIGNATURE OF OR FOR TAXPAYER: 7 DECLARATION OF APPOINTEE: a Attorney an active member of the State Bar of Arizona a Class 5 felony pursuant to A R S 42 1127(B)(2) accordance with Arizona Supreme Court Rule 31 Please specify any limitation to the Power of Attorney: ADOR 03 0033f (1/10) Apartment/Suite No ARIZONA DEPARTMENT OF REVENUE 1600 WEST MONROE PHOENIX AZ 85007 ARIZONA FORM Authorization Form authorized tax practitioner provide the practitioner s name and CAF number below: b Certified Public Accountant duly qualified to practice as a Certified Public Accountant in Arizona By signing this form I authorize the department to release confi dential information of the Taxpayer(s) named above to the appointee named above c Federally Authorized Tax Practitioner within the meaning of A R S 42 2069(D)(1) If appointee is engaged in practice with a federally City Town or Post Office City Town or Post Office State Zip Code Complete if Appointee has been given authority under Section 4 or is otherwise authorized to practice law as d Other This may be any individual providing the total amount in dispute including tax penalties and interest is less than $5 000 00 DATE SIGNATURE DATE Daytime Telephone Number (with area code) defined in Rule 31(a) of Arizona Rules of the Supreme Court Under penalties of perjury I declare that I am one of the following: DESIGNATION JURISDICTION Enter a letter (a b c or d) (State) SIGNATURE DATE for the tax year(s) specified To grant a Power of Attorney check the box in Section 4 I hereby certify that the Arizona Department of Revenue is authorized to release any and all confidential If box 5 is checked the revocation will be effective as to all earlier authorizations and Powers of Attorney on file with the Department of If this Declaration of Appointee is not signed and dated the representation authorization will be returned Individual Income Tax Disclosure/Representation information concerning the above mentioned Taxpayer I understand that to knowingly prepare or present a document which is fraudulent or false is Internal Revenue Service Enrolled Agent Number Name (List additional appointees on supplemental sheet ) of Revenue please check box 5 If you wish to revoke only some prior authorizations and/or Powers of Attorney please check box 5 and list below POWER OF ATTORNEY: By checking box 4 the taxpayer grants the above named appointee a Power of Attorney to perform any and all acts PRACTITIONER S NAME CAF NUMBER Present Address number and street rural route Present Address number and street rural route Apartment/Suite No Daytime Telephone Number (with area code) PRINT NAME Provide one of the following identifi cation numbers: Revenue except for the following persons (please specify): REVOCATION OF EARLIER AUTHORIZATION(S): This authorization does not revoke any earlier authorizations or Powers of Attorney on file SIGNATURE Social Security or Other ID No Type State and Certified Public Accountant Number State and State Bar Number State Zip Code Taxpayer Name(s) Social Security Number(s) that the taxpayer can perform with regard to the above mentioned tax matters and tax year(s) The use of a Power of Attorney must be in The appointee is authorized to receive confidential information relating to individual income tax for the following tax years: those authorizations and Powers of Attorney that you wish to remain in effect with the Arizona Department of Revenue If you want to revoke all prior authorizations or Powers of Attorney on file with the Arizona Department