Unclaimed Property Disclosure/Representation Authorization FormARIZONA DEPARTMENT OF REVENUEARIZONA FORM285UP1. CLAIMANT INFORMATION - Please print or type. Enter only those that apply: Claimant name Social Security Number(s) Present address Federal Employer Identifi cation Number City, town or post offi ce State Zip Code Daytime telephone number ( )2. APPOINTEE/DESIGNEE OF CLAIMANT INFORMATION Provide Number, as applicable: Name State and State Bar Number Present address State and Certifi ed Public Accountant Number City, town or post offi ce State Zip Code Social Security or Other ID Number Daytime telephone number ( )3. RELEASE OF CONFIDENTIAL INFORMATION. The appointee named above is authorized to receive confidential information relating to the unclaimed property of the claimant named above. By signing this form, I authorize the Department to release confi dential information of the claimant to the appointee. To grant a limited power of attorney, complete section 4. To grant a full power of attorney, complete section LIMITED POWER OF ATTORNEY. Items 4a through 4e allow the claimant to grant additional authorization to the appointee named above with regard to Unclaimed Property administrative matters before the Department of Revenue. Please check the appropriate boxes. The additional authorization must be in accordance with Arizona Supreme Court Rule 31. See instructions. 4a Appointee shall have the power to claim and collect unclaimed property on behalf of the Claimant. 4b Appointee shall have the power to sign a statute of limitations waiver on Claimant s behalf. 4c Appointee shall have the power to execute a protest of a defi ciency assessment or a denied claim or to execute an agreement on Claimant s behalf. 4d Appointee shall have the power to request a formal hearing on Claimant s behalf. 4e Appointee shall have the authority to delegate to others any or all authority granted to appointee by this document. 4f Other (please specify): 5. POWER OF ATTORNEY. By checking the box on line 5, the claimant named above grants the appointee named above a Power of Attorneyto perform any and all acts that the claimant can perform with regard to Unclaimed Property administrative matters before theDepartment of Revenue. 6. REVOCATION OF EARLIER AUTHORIZATION(S). This Authorization revokes any earlier Unclaimed Property Authorizations on fi le with the Arizona Department of Revenue for the same year covered by this 17-5535 (5/06)7. CORPORATIONS HAVING CONTROLLED SUBSIDIARIES. 42-2003(A)(1) provides that confi dential 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 offi cer of a parent corporation may execute a written authorization for a controlled subsidiary. A principal corporate offi cer of a parent corporation that desires to designate a person to receive confi dential 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 Claimant may complete the following to include all controlled subsidiaries in the disclosure authorization. Include the following controlled subsidiaries. A controlled subsidiary, for purposes of 42-2003, is defi ned as more than 50% ownership or control. NAME FEDERAL NO. 7a 7b 7c 7d 7e 7f 8. SIGNATURE OF CLAIMANT. I hereby certify that I have the authority, within the meaning of 42-2003(A), to execute this authorization form on behalf of the above claimant. I understand that to knowingly prepare or present a document which is fraudulent or false is a Class 5 felony pursuant to 42-1127(B)(2). SIGNATURE DATE PRINT NAME TITLE 9. DECLARATION OF APPOINTEE. Complete if Appointee has been given authority under Section 4 or Section 5 or is otherwise authorized to pratice law as defi ned in Rule 31 of the Arizona Rules of the Supreme Court. Under penalties of perjury, I, the above named appointee, declare that I am one of the following: a A full-time offi cer, partner, member or manager of a limited liability company, or employee if the individual qualifi es under Rule 31(c)13 of the Arizona Rules of the Supreme Court. b Attorney - an active member of the State Bar of Arizona. c Certifi ed Public Accountant - duly qualifi ed to practice as a Certifi ed Public Accountant in Arizona. d Federally Authorized Tax Practitioner within the meaning of 42-2069(D)(1). If appointee is engaged in practice with a federally authorized taxpractitioner, provide the practitioner s name and CAF number below:__________________________________ _____________________ ___________________________PRACTITIONER S NAME CAF NUMBER e Other - This may be any individual, providing the total amount in dispute, including tax, penalties, and interest is less than $5, a letter (a, b, c d or e).JURISDICTION(State)SIGNATUREDATEIf this Declaration of Appointee is not signed and dated, the representation authorization will be completed form to:Arizona Department of RevenueUnclaimed Property Unit1600 W. Monroe StreetPhoenix, AZ 85007ADOR 17-5535 (5/06)AZ Form 285UP (2006) Page 2
Unclaimed Property Disclosure/Representation …
5. POWER OF ATTORNEY. Unclaimed Property Disclosure/Representation Authorization Form ARIZONA DEPARTMENT OF REVENUE ARIZONA FORM 285UP 1. CLAIMANT INFORMATION ...
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