Tax Clearance Certificate Form

Tax Clearance Certificate Form

Taxpayer Information

Individual / Sole Proprietor    C Corporation    S Corporation
Partnership    Trust / Estate    LLC    Other (specify):

Taxpayer Identification Number (TIN)

Provide the Taxpayer Identification Number. Complete either the Social Security Number field or the Employer Identification Number field below; do not complete both unless both apply.

Clearance Requested

Specify the types of tax liabilities for which clearance is requested. Check all that apply.

State Income Tax    Sales and Use Tax    Payroll / Withholding Tax
Property Tax    Franchise / Excise Tax    Other (specify):

From: To:

Representations, Certifications and Authorization

Under penalties of perjury, the undersigned taxpayer certifies that the following statements are true, correct and complete:

1. The taxpayer identification information provided on this form is accurate and complete to the best of my knowledge.

2. To the best of my knowledge, the taxpayer has filed all required tax returns and paid all taxes, interest and penalties due for the period identified above except as expressly noted in writing on an attached schedule (attach additional pages if necessary).

3. I request issuance of a Tax Clearance Certificate for the tax types and period specified and understand that issuance is subject to review and verification by the tax authority. I acknowledge that a certificate is effective only to the extent stated by the issuing authority.

4. I authorize the tax authority to disclose tax account information necessary to process this request to the designated agent below, if any, and to the extent necessary for the issuance or denial of the clearance.

5. I understand that knowingly making a false statement on this form may subject me to criminal or civil penalties under applicable tax laws.

By checking this box and signing below I certify under penalty of perjury that the statements above are true and I am authorized to make this request on behalf of the taxpayer indicated.

Authorized Designee (optional)

If a third party is authorized to receive the clearance, provide designee information and attach authorization documentation.

Acknowledgment by Signatory

The signatory below certifies that they are authorized to execute this request on behalf of the taxpayer and that this request is made in good faith. The signatory further acknowledges that the tax authority may request additional documentation to verify the representations made herein.

Sign Now