Tax Clearance Application                                                       GENERAL INSTRUCTIONS

PURPOSE OF FORM                                                   Form.  Arizona Form 285B is available on the Arizona  
                                                                  Department of Revenue website, www.azdor.gov.
To apply for Certificate of Compliance for either, Letter of 
Good Standing,Dissolution or Withdrawal                           Section 5 - Important Information
                                                                  Power of Attorney
SPECIFIC INSTRUCTIONS
                                                                  If this application is submitted by anyone other than a 
Section 1 - Applicant Information                                 corporate officer, general partner, or individual (sole 
Enter the applicant’s name, as licensed, name of the              proprietor), Arizona Form 285B, Disclosure Authorization 
entity for which the certificate will be issued.  The             Form, is required. Visit our website at www.azdor.gov and 
application will be denied if the name does not match the         click on the Forms link to obtain Form 285B. 
Taxpayer Identification Number or the Federal Employer            Confidentiality:  The  department  does  not  release            
Identification Number entered. . (A file number per the           information to anyone other than the taxpayer or a 
Arizona Corporation Commissions has no relation to a              representative as evidenced by a valid power of attorney 
Federal Employer Taxpayer Identification Number).                 or disclosure Authorization form on file with the department 
Enter the applicant’s daytime telephone number with ext.,         or with the application. 
current mailing address, city, state and zip code.                Denied/Approval  Applications: If your application 
                                                                  is denied, a denial letter will be sent by mail. Once the 
Section 2 - Tax Clearance Purpose                                 deficiencies are cleared, you must resubmit a new 
Check the box for the type of certificate requested:              application to restart the process. If your application is 
A Certificate of Compliance for Dissolution or                    approved a certificate will be sent by mail.
Withdrawal is specifically for dissolution of a corporation or    Processing: Arizona does not have an expedited 
is for an entity wishing to withdraw from Arizona.                process for Tax Clearance Applications. An application 
A Letter of Good Standing request is for the healthy forest       for a Letter of Good Standing (A.R.S.42-1110) takes 15 
certification, air carrier apportionment, personal reason,        business days to process. An application for Dissolution 
renewable energy tax incentive, residency, sale of a              or Withdrawal (A.R.S.43-1151) takes 30 business days to 
business, or other reason.                                        process. There is no fee for this service. 
                                                                  Compliance: You must be in full compliance with any 
Section 3 - Application Type                                      and all Arizona tax filing and tax payment requirements 
Check only one box for the type of entity making the              in order to receive a certificate. All delinquent returns 
request.                                                          filed and balances must be paid in full prior to filing tax 
Enter the Federal Employer Identification Number or the           clearance application. If you are on a payment plan this 
Taxpayer Identification Number.                                   will not suffice, your account needs to be paid in full.
Enter the Arizona Transaction Privilege License Number.           Dissolution and Withdrawal: You must have cancelled 
If the business does not have one, leave blank.                   all required licenses with the department in order to receive 
                                                                  a certificate. You must have filed a final corporate income 
Enter the Arizona Withholding Tax License Number.  If the 
                                                                  tax return in order to receive a certificate.
business does not have one, leave blank.
                                                                  Other Information:
Estates or Trusts:  Enter the Taxpayer Identification 
                                                                  If your business files a consolidated return, a notarized 
Number or Federal Employer Identification Number.
                                                                  Letter of Assumption must be submitted from the ultimate 
Individuals:  Enter your Social Security Number. (Last            parent company with your application.
six years or prior will be checked)                               If your business is tax exempt or non-profit, you must 
                                                                  submit with your application a Letter of Determination from 
Section 4 - Signature                                             the Internal Revenue Service.
This area is for the signature of the individual taxpayer, 
                                                                  Application Submission:
the corporate officer, partner or member of the business 
requesting the certificate.                                       For submission details please see the following Tax 
                                                                  Clearance Application form on the next page.  
Print the name of the taxpayer.  Print the title of the taxpayer, 
owner, partner, president, vice president, etc.  Sign and 
date the application.  The name must be legible.
Unsigned applications will not be processed.
If the application is signed by anyone other than the 
taxpayer, the application cannot be processed and is 
considered invalid unless the application is accompanied 
by an Arizona Form 285B, Disclosure Authorization 
ADOR 10523 (1/18) INSTRUCTIONS

            Arizona Department of Revenue  •  Collections Administrative Support
                         ATTN: TCA Process – 1600 W. Monroe – Phoenix, AZ  85007
                                           Telephone:  (602) 716-6234

                            TAX CLEARANCE APPLICATION
1. Applicant Information:
BUSINESS OR APPLICANT NAME                                                    DAYTIME PHONE NO. (W/ AREA CODE W/EXT.)

CURRENT MAILING ADDRESS

CITY                                                     STATE                ZIP CODE

2. Tax Clearance Purpose:  Check only one request.
REQUEST FOR CERTIFICATE OF COMPLIANCE FOR DISSOLUTION OR WITHDRAWAL:
 Dissolution of Corporation (not applicable to estate, trust, or individual application types)
 Withdrawal from Arizona (not applicable to estate, trust, or individual application types)
OR 
REQUEST FOR CERTIFICATE OF COMPLIANCE FOR LETTER OF GOOD STANDING:
 Healthy Forest Certification              Residency
 Air Carrier Apportionment                 Sale of Business
 Personal                                  Other:   
 Renewable Energy Tax Incentive
 Gaming
3. Application Type:  Check only one box and provide tax identification number(s) that apply.
 Corporation                  Federal Employer I.D. No./Taxpayer I.D. No. 
 S Corporation
 Partnership or L.L.P                   AZ Transaction Privilege License No. 
 Tax Exempt Organization
 Limited Liability Company                AZ Withholding Tax License No. 
 Limited Liability Partnership
 Estate                                                 Social Security No. 
 Trust
 Individual 
 Sole Proprietor
4. Signature
                                                            
PRINT NAME                                                 PRINT SPECIFIC TITLE (President, Officer, Partner, Individual)
                                                            
SIGNATURE                                   DATE
5. How to submit application:
Email completed and signed application to: tca@azdor.gov • Be sure to sign the application.
Mail or Deliver to:                                      • If your application is denied, you must clear all 
         Arizona Department of Revenue                     deficiencies and resubmit the application.
                    Attn: TCA Process                    • If this application is submitted by anyone other than a 
                    1600 West Monroe                       corporate officer, general partner, or individual (sole 
                 Phoenix Arizona 85007                     proprietor), Arizona Form 285B, Disclosure Authorization 
FAX completed and signed application to:                   Form, is required. Visit our website at www.azdor.gov 
                                                           and click on the Forms link to obtain Form 285B.
       602-542- 4771   Attn: TCA Process
ADOR 10523 (1/18)
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