Tax Authorization Consent

Tax Authorization Consent

Taxpayer Name:

Business Name (if different):

Taxpayer Identification

Entity Type (select one or more that apply)

Individual/Sole Proprietor
C Corp
S Corp
Partnership
Trust/Estate
LLC
Other (describe below)

Taxpayer Identification Number (TIN)

Check which number is provided and enter the number below. Only one TIN is required; entering both is allowed only to clarify identity.

Social Security Number (SSN):

Employer Identification Number (EIN):

Authorized Representative

Scope of Authorization

The Taxpayer authorizes the Representative to take the following actions with respect to federal, state and local tax matters as indicated below:

Discuss and receive tax information and records from taxing authorities and third parties
Obtain copies of tax returns, transcripts, notices, and other records
Represent Taxpayer before tax authorities for audits, examinations and appeals
Sign tax returns, disclosures, or consents on behalf of the Taxpayer where permitted by law
Limited authorization only (describe limitations below)

Tax Periods Covered

From:    To:

Limitations, Effective Period and Revocation

This authorization does not permit the Representative to alter, amend, or execute tax returns beyond the specific authority granted herein except where expressly authorized by the Taxpayer in writing. The Taxpayer may revoke this Authorization in writing at any time. Revocation does not affect actions properly taken by the Representative prior to receipt of written revocation by the Representative and the relevant taxing authority.

This Authorization is effective on the date signed and remains in effect until the earlier of: (a) written revocation by the Taxpayer; (b) the end date specified in the Tax Periods Covered section; or (c) termination in writing signed by both the Taxpayer and Representative.

Certification and Perjury Statement

By signing below, the Taxpayer certifies under penalties of perjury that the following statements are true and correct:

1. The Taxpayer is the individual or entity identified above and the information provided on this form is true, complete and accurate to the best of the Taxpayer's knowledge.

2. The Taxpayer authorizes the Representative to receive and discuss confidential tax information and to take the actions described in the Scope of Authorization above for the tax periods identified herein.

3. The Taxpayer understands that this Authorization permits the Representative to obtain tax returns, transcripts, notices, and other tax records and that the Representative may disclose such records to agents, counsel, or professional advisors as necessary to carry out the authorized tasks.

4. The Taxpayer acknowledges that the Representative may disclose confidential tax information to third parties only as necessary to perform the authorized services and as permitted by law, and will maintain confidentiality consistent with professional obligations.

5. The Taxpayer understands that this Authorization does not relieve the Taxpayer of any legal obligations to supply correct information to taxing authorities and that the Taxpayer remains responsible for the accuracy and completeness of all tax returns and filings.

6. The Taxpayer further certifies that, if required, the Taxpayer's TIN is provided and is correct and that the Taxpayer is not subject to backup withholding except as indicated on this form.

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