Arizona Form  
                                                 General Disclosure/Representation Authorization Form
                   285
                                                 You must sign this form on page 2
1.  TAXPAYER INFORMATION:  Please print or type.                                                     Enter only those that apply:
Taxpayer Name                                                                                        Social Security Number or ITIN

Spouse’s Name (if applicable)                                                                        Spouse’s Social Security Number or ITIN

Current Address - number and street, rural route                      Apartment/Suite No.            Employer Identification Number

City, Town or Post Office      State             ZIP Code             Daytime Phone (with area code) AZ Transaction Privilege Tax License No.

2.  APPOINTEE INFORMATION  (Must sign if any checkboxes in Sections 4 or 5 below are selected) Enter one of the following identification numbers:
Name (must be an individual)                                                                   State and State Bar Number
                                                                                                   |
Current Address - number and street, rural route                      Apartment/Suite No. State and Certified Public Accountant Number
                                                                                                   | 
City, Town or Post Office                                  State      ZIP Code                 Internal Revenue Service Enrolled Agent Number

Daytime Phone (with area code)                                                                 Social Security, ITIN, or Other ID No.  Type
                                                                                                                                 |
3.  TAX MATTERS:  The appointee is authorized to receive confidential information for the tax matters listed below.  By signing this form, I authorize 
    the Department to release confidential information of the taxpayer(s) named above to the appointee named above for the tax type and tax year(s)/
    period(s) specified below.  To grant additional powers, please see Section 4.  To grant a Power of Attorney, please skip Section 4 and go to 
    Section 5.
      TAX TYPE                 YEAR(S) OR PERIOD(S)                                  TYPE OF RETURN/OWNERSHIP
    Income Tax                                           Individual                           Corporation
                                                          Partnership                          Fiduciary-Estate/Trust
    Transaction Privilege                                Individual/Sole Proprietorship       Partnership    Corporation    Trust
      and Use Tax                                         Limited Liability Company            Limited Liability Partnership  Estate
    Withholding Tax

    Other (e.g., Luxury Tax):                           Specify type of return(s)/ownership:

4.  ADDITIONAL AUTHORIZATION:  Items 4a through 4h allow the Taxpayer(s) to grant additional authorization to the Appointee named above.  Please 
    check the boxes accordingly.  An additional authorization must be in accordance with Arizona Supreme Court Rule 31. See instructions.  If any 
    checkboxes in Sections 4 or 5 are selected, the Appointee MUST sign on Page 2, Section 9. 
   4a  Appointee shall have the power to sign a statute of limitations waiver on Taxpayer’s behalf.
   4b  Appointee shall have the power to execute a protest of a deficiency assessment or a denied refund claim or to execute an 
      agreement on Taxpayer’s behalf.
   4c  Appointee shall have the power to request a formal hearing on Taxpayer’s behalf.
   4d  Appointee shall have the power to represent the taxpayer in any administrative tax proceeding.
   4e  Appointee shall have the power to execute a closing agreement on Taxpayer’s behalf.
   4f  Appointee shall have the power to represent the taxpayer in any collection matter including an Offer-In-Compromise.
   4g  Appointee shall have the authority to delegate to others any or all authority granted to appointee by this document.
   4h  Other (please specify):
    
5.   POWER OF ATTORNEY:  By checking the box on Section 5, the taxpayer grants the above-named appointee a Power of Attorney to perform any 
      and all acts that the taxpayer can perform with regard to the above-mentioned tax matters and tax year(s) or period(s).  This Power of Attorney 
      includes, but is not limited to, the powers listed in items 4a through 4h.  The use of a Power of Attorney must be in accordance with Arizona 
      Supreme Court Rule 31.  Please specify any limitation to the Power of Attorney:
 
6.     REVOCATION OF EARLIER AUTHORIZATION(S):  By checking the box in Section 6, I revoke all prior authorizations filed with the Arizona 
      Department of Revenue.  The revocation will be effective as to all earlier authorizations and Powers of Attorney on file with the Arizona Department 
      of Revenue except those specified (please specify):
 
ADOR 10952 (8/18)                                                                                                Continued on Page 2   

      Taxpayer Name (as shown on page 1)                                                                               Taxpayer Identification Number

7.  CORPORATIONS HAVING CONTROLLED SUBSIDIARIES:  A.R.S. §42-2003(A)(1) provides that confidential information relating to a corporate 
             taxpayer may be disclosed to a designee of the taxpayer who is authorized in writing by the taxpayer.  A principal corporate officer of a parent 
             corporation may execute a written authorization for a controlled subsidiary.  A principal corporate officer of a parent corporation that desires to 
             designate a person to receive confidential information regarding the corporation’s controlled subsidiaries must either attach a list containing the names 
             of each controlled subsidiary that the parent company wants included in the disclosure authorization (a federal Form 851 may be used for this purpose) 
             or taxpayer may complete the following to include all controlled subsidiaries in the disclosure authorization.  In addition, there is space provided to 
             exclude specific controlled subsidiaries from the disclosure authorization.
            Please check one of the following:
                     Include all controlled subsidiaries.  A controlled subsidiary, for purposes of A.R.S. §42-2003, is defined as more than 50% ownership or control.
                     Include all controlled subsidiaries except the subsidiaries named below.  The following controlled subsidiaries are specifically excluded:
                                                    NAME                                        EMPLOYER I.D. NO.                        TAX YEARS (if not all years)
                  7a                                                                                                      
                  7b                                                                                                      
                  7c                                                                                                      
                  7d                                                                                                      
                  7e                                                                                                      
                  7f                                                                                                      

8. SIGNATURE OF OR FOR TAXPAYER:  I hereby certify that the Arizona Department of Revenue is authorized to release any and 
             all confidential information concerning the Taxpayer(s).  By signing this form, I certify that I have the authority, within the meaning of                   
             A.R.S. §42-2003(A), to execute this authorization form on behalf of the Taxpayer(s).  I understand that to knowingly prepare or present a document 
             which is fraudulent or false is a Class 5 felony pursuant to A.R.S. §42-1127(B)(2).

                     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).

                                                                                                 
 SIGNATURE                                                             DATE                            SIGNATURE                                        DATE
                                                                                                   
                     PRINT NAME                                                                        PRINT NAME
                                                                                                   
 TITLE                                                                                                 TITLE
9.  DECLARATION OF APPOINTEE:  Complete if Appointee has been given authority under Section 4 or Section 5 or is otherwise authorized to practice 
             law as defined in Rule 31(a) of the Arizona Rules of the Supreme Court.
             Under penalties of perjury, I declare that I am one of the following:
                  9a A full-time officer, partner, member or manager of a limited liability company, or employee if the individual qualifies under Rule 31(d)(13) of the 
                     Arizona Rules of the Supreme Court.
                  9b Attorney - an active member of the State Bar of Arizona.
                  9c Certified Public Accountant - duly qualified to practice as a Certified Public Accountant in Arizona.
                  9d Federally Authorized Tax Practitioner within the meaning of A.R.S. §42-2069(D)(1).  If Appointee is engaged in practice with a federally 
                     authorized tax practitioner, provide the practitioner’s name and CAF number below:
                                                                                                        
                    PRACTITIONER’S NAME                                                                CAF NUMBER
                  9e Other - This may be any individual, providing the total amount in dispute, including tax, penalties, and interest is less than $5,000.00.
             If this Declaration of Appointee is not signed and dated, the representation authorization will be returned.
                          DESIGNATION                    JURISDICTION
                  Check one box for each Appointee:      (State)                                            SIGNATURE                                       DATE

                     9a  9b  9c  9d  9e

                     9a  9b  9c  9d  9e

                     9a  9b  9c  9d  9e

                     9a  9b  9c  9d  9e

 ADOR 10952 (8/18)                                                                AZ Form 285                                                                 Page 2 of 2
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