North Dakota Authorization to Disclose Tax Information & Designate a Representative

Authorization to Disclose Tax Information & Designate a Representative
Form 500 - Authorization To Disclose Tax Information & Designation Of Representative
AUTHORIZATION TO DISCLOSE TAX INFORMATION
& DESIGNATION OF REPRESENTATIVE
OFFICE OF STATE TAX COMMISSIONER

Form 500

SFN 28258 (4-2020)

Taxpayer Information
Name of Individual, Estate, Trust, Partnership, Corporation, LLP, or LLC

Telephone Number

Social Security Number or FEIN Number

Name of Spouse, Fiduciary or Personal Representative (if applicable)

Telephone Number

Social Security Number or FEIN Number

Mailing Address

State

City

Email Address

ZIP Code

Fax Number

Designated Individual or Firm
Name of Individual (or Firm)
Mailing Address

Telephone Number
City

Social Security Number or FEIN Number
State

ZIP Code

Fax Number

Email Address

Authorization or Revocation - Check the applicable box(es):

• An authorization to disclose tax information or designation of representative on Form 500 does not apply to the routine mailing of tax
forms, refund checks, original notices (e.g., Notice of Determination), or other original written communications, which are always
mailed to the taxpayer.
• Form 500 takes effect upon receipt by the Office of State Tax Commissioner and remains in effect until revoked by the taxpayer.
A. Authorization To Disclose Tax Information. The Tax Commissioner is authorized to disclose confidential tax information on file
with the Office of State Tax Commissioner to the above-designated individual or firm with respect to the following matters:
Type of Tax

Form Number

Tax Year or Period

Type of Tax

Form Number

Tax Year or Period

B. Designation of Representative. The Tax Commissioner is notified that the above-designated individual or firm has been authorized
to represent the above-named taxpayer(s) before the Office of State Tax Commissioner with respect to the following matters:
Type of Tax

Form Number

Tax Year or Period

Type of Tax

Form Number

Tax Year or Period

This designation of representative also authorizes the Tax Commissioner to disclose confidential tax information on file with the Office of State
Tax Commissioner to the representative. The representative is authorized to perform all acts that the taxpayer can perform except that only an
individual admitted and licensed to practice law in North Dakota may sign a complaint, represent the taxpayer in a formal administrative review
under North Dakota Century Code ch. 28-32, or represent the taxpayer in any court proceeding.

C. Authorization To Disclose Tax Information Using Facsimile (Fax) or E-mail. The Tax Commissioner is authorized to use facsimile
or e-mail, or both, to disclose confidential tax information on file with the Office of State Tax Commissioner to the above-designated individual
or firm with respect to the above-identified matters.

D. Revocation. The Tax Commissioner is notified that all authorizations previously made are revoked for ALL previously designated individuals
or firms. To revoke authorizations for only a specified individual or firm, complete the designated individual or firm information section above.
(If this box is checked, do not check Box A, Box B, or Box C.)
Signature of Taxpayer(s)
Signature

Printed Name

Date

Spouse's Signature, if Applicable

Printed Name of Spouse

Date

Privacy Act Notification. In compliance with the Privacy Act of 1974, disclosure of a social

security number or Federal Employer Identification Number (FEIN) on this form is required
under N.D.C.C. § 57-01-15, and will be used for tax reporting, identification, and administration
of North Dakota tax laws. Disclosure is mandatory. Failure to provide the social security number
or FEIN may delay or prevent the processing of this form.

For Office Use Only

Form 500 Instructions
SFN 28258 (4-2020)
General Instructions
Form 500 may be used by a taxpayer to
do one of the following:
	

	

Authorize the North Dakota Office
of State Tax Commissioner to
disclose the taxpayer’s confidential
tax information to another individual
or firm not otherwise entitled to the
information.
Designate another individual or
firm to represent or act on behalf
of the taxpayer before the Office
of State Tax Commissioner, and to
authorize the North Dakota Office
of State Tax Commissioner to
disclose the taxpayer’s confidential
tax information to the designated
representative or firm.

Form 500 does not apply to the routine
mailing of tax forms, refund checks,
original notices (e.g., a Notice of
Determination), or other original written
communications, which are always mailed
to the taxpayer.
Unless Box C on Form 500 is checked
to authorize the sending of confidential
tax information by facsimile (fax)
transmission or email, the Office of State
Tax Commissioner will send confidential
tax information authorized by Form 500
to the designated individual or firm only
by letter or telephone.
Changing a previously filed Form 500.
To change a Form 500 previously filed
with respect to a particular designated
individual or firm, complete and file
a new Form 500 for that designated
individual or firm. The new Form 500
automatically revokes and replaces the
previously filed Form(s) 500.
Revoking a previously filed Form 500.
To revoke a previously filed Form 500,
see instructions to Box D under
“Authorization or Revocation.”
When Form 500 takes effect. Form 500
takes effect upon receipt by the Office of
State Tax Commissioner and remains in
effect until revoked by the taxpayer.

Specific Instructions
Taxpayer Information

Enter the taxpayer’s name, social security
number or federal employer identification
number (FEIN), mailing address, and
contact information.
For a trust, enter the trust’s name and
FEIN, and the name, mailing address, and
contact information of the fiduciary.
For an estate, enter the decedent’s name
and social security number, and the name,
mailing address, and contact information
of the decedent’s personal representative
or fiduciary.
Designated Individual or Firm

Enter the name, social security number or
federal employer identification number
(FEIN), mailing address, and contact
information for the designated individual
or firm. If designating more than one
individual or firm, attach a statement
listing each one.
Note: Do not complete this section of
the form if filing this form to revoke
previously filed Forms 500 and the
revocation is intended to apply to all
previously designated individuals and
firms.
Authorization or Revocation

For Box A and Box B, the authorization
to disclose or the designation of
representative can be limited to a certain
tax type (e.g., individual income tax or
sales tax), form number, or taxable year or
period by entering that information in the
spaces provided.
If attaching a statement to identify
additional designated individuals or firms,
indicate the authority being given to each
one by entering “Box A” or “Box B” (and
“Box C” if desired) next to each one listed
on the statement.
Box A -	 Check this box to authorize the
Office of State Tax Commissioner to
disclose confidential tax information to
the designated individual or firm.
Box B -	 Check this box to designate an
individual or firm to represent or act on
behalf of the taxpayer before the Office of

State Tax Commissioner, and to authorize
the Office of State Tax Commissioner to
disclose confidential tax information to
the designated individual or firm.
Box C - Check this box to authorize the
Office of State Tax Commissioner to
send confidential tax information to the
designated individual or firm by facsimile
(fax) transmission or email.
Box D - Check this box to revoke all
previously filed Forms 500. To limit
the revocation to a specific designated
individual or firm, identify that individual
or firm by completing the “Designated
Individual or Firm” section of the form.
Otherwise, leave that section of the
form blank to apply the revocation to all
previously designated individuals and
firms. If checking this box, do not check
any of the other boxes (A, B, or C) on the
form.
Signature of Taxpayer(s)

Partnership (all types). One of the general
partners must sign.
Corporation. An officer having authority
to bind the corporation must sign.
Limited liability company. A governor or
manager must sign.
Estate, trust, or any other situation where
there is a fiduciary relationship. The
personal representative, trustee, guardian,
conservator, or other fiduciary must sign.
Where to Send Form 500
Form 500 may be submitted to the North
Dakota Office of State Tax Commissioner
by fax, email, or regular mail.
Fax or email
Income & Withholding Taxes—
	Fax	
701.328.1942
	Email	
[email protected]
Business Registration—
	Fax	
701.328.0332
	Email	
[email protected]
General (other tax or purpose)—
	Fax	
701.328.3700
	Email	
[email protected]
Regular mail
	 Office of State Tax Commissioner
	 600 E. Boulevard Ave., Dept. 127 		
	 Bismarck, ND 58505-0599