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150 602 005 2017-2023
Representative
Phone numbers (include cell, home, and work numbers)
Address
City
State
ZIP code
I authorize the Department of Revenue to disclose my confidential OAA debt information to my authorized representative. This may
include, but is not limited to, disclosure of dates when debt occurred; type of debt; and to whom debt is owed.
I authorize my authorized representative to set up a payment plan; manage all payments and settlement offer(s); obtain balance
information; and resolve any...
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