ARIZONA FORM
                              Disclosure Certification Form
    285C                                         ARIZONA DEPARTMENT OF REVENUE

      This form should be used to certify to the Department that the person named below (“Signator”) is authorized, 
      pursuant to A.R.S. §42‑2003(A), to receive and discuss confidential information of the Taxpayer(s) named below or 
      to execute a power of attorney form for another person.

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 Number         Employer Identification Number

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

2.  SIGNATOR INFORMATION                                            You must provide an Identification Number:
Name                                                                Social Security, ITIN or Other ID No. Type
                                                                                                          |
Business Address (if different from Taxpayer’s address above)       Apartment/Suite Number   Daytime Phone Number (with area code) 

City, Town or Post Office                                     State ZIP Code

3.  TAX YEARS / PERIODS
Please specify the tax years/periods during which the Signator is authorized, pursuant to A.R.S. §42‑2003(A), to receive and 
discuss confidential information or to execute a power of attorney form for another person:

4.  CERTIFICATION
  A.   I hereby certify to the Arizona Department of Revenue that I am authorized to receive and discuss any and all confidential 
      information concerning the Taxpayer(s) pursuant to A.R.S. §42‑2003(A).  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).

  B.   I hereby certify to the Arizona Department of Revenue 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), of the above‑mentioned corporation(s) 
      who has the authority to bind the taxpayer on matters related to the state taxes.

5.  SIGNATURE

  
     SIGNATURE                                                               DATE

     PRINT NAME

     TITLE

ADOR 10954 (8/18)
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