State of Arizona
                                           Offi  ce of Administrative Hearings
                                           Supplemental Power of Attorney

Purpose of Form  The Department of Revenue has transferred a contested matter t          o the Offi ce of Administrative Hearings 
for  ahearing.  The Arizona statutes require written authorization before the Offi ce of Administrative Hearings can disclose 
confi  dential tax information to a taxpayer’s representative.  This supplemental power of attorney form must be fi  lled out by 
the appointed representative and fi  led with the Offi  ce of Administrative Hearings in order that the Offi  ce may deal with the 
appointed representative in the matter(s) transferred to the Offi  ce by the Department of Revenue.

Authority Granted  This supplemental power of Attorney authorizes the individuals named herein to receive and inspect 
confi  dential tax information and to perform any and all acts the taxpayer(s) can perform with respect to these matters in 
dealing with the Offi  ce of Administrative Hearings.

1. Taxpayer Information                                                                2. Applicable Identifi  cation Number
                                        Daytime telephone number                       Arizona transaction privilege tax number
Taxpayer name(s)                        ( )
                                                                                       Federal employer identifi  cation number

Address                                                                                Social security number

City                                      State                       ZIP code

3. Representative(s)
 
Name and address                                                      ID number

                                                                      Telephone number (   )

                                                                      Fax number (       )

Name and address                                                      ID number

                                                                      Telephone number (   )

                                                                      Fax number (       )

4. Tax Matters

      Tax type                                  Entity/Type of return                                        Case Number
Transaction         Sole Proprietorship              Partnership
Privilege Tax
                    Corporation                  

Use                 Sole Proprietorship              Partnership

                    Corporation                  

Other
(Specify Tax
Type)

ADOR 01-5414  (3/03)

Page 2
5. Acts Authorized
The representative(s) is/are authorized to receive and inspect confi  dential tax information and to perform any and all acts that the taxpayer can perform with respect 
to the tax matters in question, for example, the authority to sign any agreements, consents, or other documents.

List any specifi  c restrictions to the acts otherwise authorized in this power of attorney:

6. Notice and Communications
Send copies of notices and other written communications addressed to the taxpayer(s) in proceedings involving the above tax matter to:

 1.  The representative fi  rst named above, or ..................................................................
 2.  Names of not more than two of the above named representative .............................

7. Retention of Prior Power(s) of Attorney
The fi  ling of this supplemental power of attorney is in addition to a valid executed power of attorney with the Department of Revenue and does not revoke any 
earlier valid power(s) of attorney on fi  le with the Department of Revenue for the same tax matters.
Please attach a copy of any Department of Revenue power of attorney.
8. Signature for Taxpayer(s)

As appointed representative for the taxpayer(s), I hereby certify that the Director of Offi  ce of Administrative Hearings, State of Arizona, is authorized to release any 
and all information in Offi  ce fi  les concerning the named taxpayer and relieve said Director, or Offi  ce representative, of any liability whatsoever for releasing such 
taxpayer information to the person(s) named in this supplement power of attorney.  I certify that I have the authority to execute this supplemental power of attorney 
on behalf of the taxpayer(s).
If this power of attorney is not signed, it will be returned.

 (Representative Signature)                                                (Title, if applicable)                                                                                        Date

         Print Name

 (Representative Signature)                                                (Title, if applicable)                                                                                        Date

         Print Name

MailMail ThisThis To:To:   Offi Offi  cece ofof AdministrativeAdministrative Hearings,Hearings, 14001400 WW Washington,Washington, SuiteSuite 101,101, Phoenix Phoenix  AZ AZ  85007.85007.

ADOR 01-5414  (3/03)