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Disclosure Authorization Form RD-1062 - Georgia

Disclosure Authorization Form Form. This is a Georgia form and can be used in Alcohol And Tobacco Division Department Of Revenue Statewide .
 Fillable pdf Last Modified 11/2/2011
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RD 1062 Georgia Department of Revenue Email: taxadv@dor.ga.gov Fax: (404) 417-6651 (Revised 8/2011) Mailing Address: Georgia Department of Revenue PO Box 49708 Atlanta,GA 30359-0708 Print or Type Taxpayer(s) name(s) and address Disclosure Authorization Form Enter only those that apply Federal Employer ID No. Social Security No. Georgia State Tax ID No. Georgia Sales Tax Registration No. 1. Taxpayer Information Daytime Telephone Number Georgia Withholding Tax No. Appointee name and address 2. Appointee Information State and State Attorney Bar Number Provide one of the following identification numbers Social Security or other identification number (for other ID provide number and type) State and Certified Public Accountant Number Daytime Telephone Number 3. Tax Matters. The appointee is authorized to receive confidential information for the tax matter listed below: Tax Type [] Year(s) or Period (s) Personal Income Tax....................................................... Sales and Use Tax .......................................................... Corporate Income Tax..................................................... Withholding Tax............................................................... 4. Revocation of Earlier Authorization(s). This disclosure authorization form does not revoke any prior (please specify): Other (specify) authorization forms on file with the Department unless the following box is checked: If the box is checked, the revocation will be effective as to all earlier authorizations on file with the Department of Revenue except 5. Signature of or for the Taxpayer. I hereby certify that the Georgia Department of Revenue is authorized to disclose and/or discuss confidential information or records concerning the undersigned taxpayer to the appointee named above for the tax type(s) and period(s) named above. If signed by a corporate officer, member, partner, trustee or executor/executrix, I certify that I have the authority to execute this authorization form on behalf of the taxpayer. I understand that to willfully prepare or present a document that is fraudulent or false is a misdemeanor under O.C.G.A. ยง 48-1-6. Date: Signature: Print Name: Title (if applicable): The person signing as or for the taxpayer appeared this day before a notary public and acknowledged this disclosure authorization form as a voluntary act or deed. Signature of Notary Date NOTARY SEAL 1 American LegalNet, Inc. www.FormsWorkFlow.com RD1062 Disclosure Authorization Form Purpose of Form A taxpayer may use Form RD1062 to authorize the Georgia Department of Revenue to disclose and/or discuss confidential tax information for such taxpayer with an appointee for a specific tax type(s) and period(s). Form RD1062 cannot be used as a Power of Attorney and thus does not grant the appointee any powers of representation. Filing Instructions If the taxpayer is working with a specific Department section or employee of the department, the taxpayer should deliver Form RD1062 to that section or employee. Otherwise, the taxpayer may either: (1) Attach a copy of this form as an attachment to an electronic mail message and send it to taxadv@dor.ga.gov ; (2) Send a copy of the form via fax to (404) 417-6651; or (3) Mail the original or a copy of the form to: Georgia Department of Revenue PO Box 49708 Atlanta, Georgia 30359-0708 Specific Instructions Section 1 - Taxpayer Information Individuals - Enter your name, address, and any applicable identification numbers. Section 2 - Appointee Enter the appointee's name, address, and any applicable identification numbers. Section 3 - Authorization Enter the tax type(s) and specific period(s) or year(s) for which the authorization is granted. A general reference to "all years" or "all periods" is not acceptable. Section 4 - Retention/Revocation of Prior Disclosure Authorization Forms All existing disclosure authorization forms previously filed by the taxpayer will not be revoked unless the taxpayer checks the box on this line. If the taxpayer checks off this box but does not want to revoke all existing disclosure authorization forms, the taxpayer should either specify the forms that the department should retain or attach a copy of such existing form(s). A taxpayer may revoke a disclosure authorization form without authorizing a new appointee by filing with the department either: (1) A statement of revocation signed by the taxpayer indicating that the authority of the previous disclosure authorization form is revoked along with the name and address of each appointee whose authority is revoked; or (2) A copy of the disclosure authorization form to be revoked clearly marked "REVOKED." It is important to note that the filing of a Form RD1062 disclosure authorization form will not revoke any Power of Attorney that is in effect. Section 5 - Signature of Taxpayer Taxpayer Individuals Corporations Partnerships Trusts Estates Limited Liability Companies Who must sign The individual/sole proprietor must sign. A corporate officer or a person designated by a corporate officer must sign. A partner having authority to act in the name of the partnership must sign. A Trustee must sign. An Executor/Executrix or the personal representative of the estate must sign. A member having authority to act in the name of the company must sign. 2 American LegalNet, Inc. www.FormsWorkFlow.com
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