WAIVER AND AUTHORIZATION TO RELEASE  
                                                        CONFIDENTIAL TAXPAYER INFORMATION 
                                                                                     Form 21-003-14

Name of Bonded Principal:  

Doing Business As (if applicable):  

Street Address:  

City:                                                                       State: 

Tax Account ID:  __ __ __ __ - __ __ __ __ 

Name of Surety:  

Street Address:  

City:                                                                       State: 

Bond No.:  

Pursuant  to the provisions of Miss. Code Ann.  §27-65-21, the above-named bonded principal and surety have  executed a 
tax bond in favor of the State of Mississippi, guaranteeing payment of sales taxes, use taxes, income taxes,  franchise taxes, 
withholding taxes and/or petroleum taxes, as the case may be.  The above-named taxpayer hereby waives the confidentiality 
provisions of Miss. Code Ann. Sections 27-3-73, 27-7-1, et. seq., 27-13-1, et. seq., 27-55-1, et. seq. and 27-67-1 et. seq., as 
follows: 

         1.      Bonded Principal authorizes the  Mississippi Department of Revenue (“MDOR”) and its employees  to notify 
                 the referenced Surety of any unpaid tax assessment(s) the MDOR may make against the  bonded principal 
                 for unpaid tax liabilities as a result of an audit. 
         2.      The disclosure(s) made pursuant to this waiver are being provided as a voluntary accommodation to the  
                 Surety and the MDOR is under no legal obligation to make said disclosure.  The express purpose of  the 
                 disclosure is to notify a Surety of a possible liability it may be obligated to pay under the terms of the  
                 referenced bond and in an effort to effect the collection on said assessment(s).   The notification described  
                 by Section 1 shall be made promptly after the assessment is made and within the time necessary for the  
                 Bonded Principal to file an appeal. 
         3.      The assessment is not a finally determined liability and may be subject to appeal and/or adjustment. 
         4.      This waiver does not create an automatic right of representation of the bonded principal by the Surety.    
                 However, the Surety may participate in the administrative appeal process with the express consent of the  
                 bonded principal. 
         5.      Neither  the existence and/or substance of this waiver nor the failure of the MDOR to make a disclosure 
                 pursuant to this waiver prohibits the MDOR from exercising its rights against the Surety pursuant to Miss. 
                 Code Ann.  §27-65-57. 
         6.      The waiver and authorization to release confidential  taxpayer information shall be effective until the MDOR 
                 receives written notification from the bonded principal that this waiver and authorization to release 
                 confidential information is rescinded. 

                                     INSTRUCTIONS FOR SIGNING 

This waiver and authorization must be signed by the bonded principal named above.   In the case of an individual bonded 
principal, this form must be signed by that individual.  In  the case of a partnership, this form must be signed by any  member 
of the partnership during any par t of the period covered by referenced  bond.  In the case of a member managed  limited 
liability company, this form must  be signed by any person who was a member  if the limited liability company during  any part 
of the period covered by the bond.   In the case of a manager managed limited liability company, this form must be  signed by 
any manager of the limited liability company.  In the case of a corporation, this form must be signed by a principal  officer of 
the corporation and attested to by the corporation’s secretary or other officer. 

        This the ______ day of ___________, 20___. 

                  Signature 

                  Capacity 

ATTEST (In the case of corporations) 

By:  

Title:  

                                          ACKNOWLEDGEMENT 

State of  
County  of  

        Personally appeared before me, the undersigned authority in and for the said county and state, on this _______ day 

of ___________________, 20___, within my jurisdiction, the within named ______________________________________, 

who acknowledged that he/she executed the above and foregoing instrument after having been duly authorized  so to do. 

                                                   Notary Public

My Commission Expires: __________________ 

(SEAL)