Arizona Form  
                                                  Withholding Tax Information Authorization
               821

1.  Taxpayer Information    Taxpayer must sign and date this form in Section 5.
Taxpayer Name                                                                       Employer Identification Number (EIN)

Address (Number and street or PO Box)                                               Daytime Phone Number (with area code)

City                                                                                State        ZIP Code

2.  Appointee Information
Name                                                                                Identification Number

Address (Number and street or PO Box)                                               Phone Number (with area code)

City                                  State                      ZIP Code           Fax Number (with area code)

3.  Authorization

The appointee is authorized to inspect and/or receive confidential Arizona withholding tax information for the following tax year(s) 
or period(s):

4.  Retention/Revocation of Withholding Tax Information Authorization

This withholding tax information authorization automatically revokes all earlier withholding tax information authorization(s) on file 
with the Arizona Department of Revenue for the same years or periods covered by this document.  If you do not want to revoke a 
prior withholding tax information authorization, check this box ................................................................................................... 
     Document
              You must include a copy of any withholding tax information authorization you want to remain in effect.

5.  Signature of or for Taxpayer
I hereby certify that the director of the Arizona Department of Revenue is authorized to release any and all Arizona withholding 
tax information in department files concerning the undersigned taxpayer and relieve said director, or department representative, 
of any liability whatsoever for releasing such withholding tax information to the appointee specified by this authorization.  If signed 
by a corporate officer or partner, I certify that I have the authority to execute this authorization on behalf of the taxpayer(s). 
 
   By checking this box and signing below I certify under penalty of perjury that I am an officer of the above mentioned corporation(s) and that I
     am a principal officer; as defined in A.R.S. §42-2003(A)(2).
               If this withholding tax information authorization is not signed and dated, it will be returned.

Print Name                                                                Print Name

Signature                                                                 Signature

Date                                                                      Date

     You may Mail form to:  Arizona Department of Revenue, ATTENTION: POA, PO Box 29086, Phoenix, AZ  85038-9086, or 
                                      Fax form to: (602) 716-6088, or email form to POA@azdor.gov
ADOR 10172 (21)
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