Arizona Form  
                                                               Disclosure Authorization Form
                 285B
                                            You must sign this form in section 5
This form authorizes the Department to release confidential information of the taxpayer(s) named below to the appointee(s) named below 
for the tax type(s) specified below.  This form is NOT A POWER OF ATTORNEY and DOES NOT grant the appointee(s) any powers of 
representation.
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                                                 2nd APPOINTEE INFORMATION (if applicable)
Name                                                                      Name

Current Address (if different from taxpayer’s address above)  Apt./Suite Current Address (if different from taxpayer’s address above)    Apt./Suite

City, Town or Post Office                   State ZIP Code                City, Town or Post Office                      State ZIP Code

Daytime Phone (with area code)                                            Daytime Phone (with area code)

Social Security, ITIN, or Other ID No. Type                               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.  
           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.  NO REVOCATION OF EARLIER AUTHORIZATION(S)
 This Disclosure Authorization Form does not revoke any prior Power of Attorney or other authorization forms on file with the department.
5.  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

ADOR 10955 (8/18)
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