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NYC DEPAR TM ENT OF FIN AN CE AU DI T DIV ISI ON
TM
AGRE EM EN T TO AUT HO RIZE EL ECTRONI C
Financ e
TRAN SM IT TAL OF TAX IN FORMA TION
Name of Taxp aye r: ______ ___ _____FI RST NAM E____ _____ ____ _____LAST NAME_______ ___ Type(s) of Tax: ________ _________ _________________
Taxpayer ʼs NYC Adm in. Code,
E-mai l Addr ess: ___ ____ ____ ____ _____ ____ _____ ____ ___ ________ Title 11, Chapter( s) ________ _________ ______________
Taxpayer ʼs Taxpayerʼs
Phone Num ber: (___ ___ __ ) ______ __________ _________ Fax Number: (________ )____ __ ___ __ _____ __ __ __ ___ ___ _
Name of Represen tativeʼs
Represe nta tive:____ ____ ____FI RST____NAM E _________ _________LAST NAME___ _______ E-mail Address: ______ _________ __________________
Repre se ntat iveʼs Repres ent ati veʼs
Phone Num ber: (___ __ ___ ) ___________ ______________ Fax Number: (_____ ___ ) __ __ ___ ___ __ __ ___ __ __ ___ ___ _
Ef fecti ve Da te of Agre eme nt:MO__NT____H / __DA____Y /__ __YEAR________ En d Dateof Agreement: ________MONTH /__ ______DAY /________YEAR
The Ta xpa yer hereby au th or izes th e Ne w Yor k City Dep ar tme nt of Fi nance (“D OF”) to tra nsmi t ta x se cret inf ormat ion per tain ing to
th e Ta xpay er wit h the Tax pa yer or th e Ta xp aye rʼs Re pre sen ta tive usi ng e-mail, web sites, or other int ern et- bas ed service (h ere -
ina fter refe rre d to as “the electr on ic tra nsm ittal of inf orm at ion") .
DOF is ag re eing to the electr on ic tr ans mitta l of inf or mat ion sol el y for the conve nie nce of the Ta xpaye r or the Tax payer' s Re presen -
ta tiv e. Th e tax secret inf orma tion tha t will be tra nsm itted in such man ner may includ e th e Taxpay erʼs tax re turns or informa tio n co n-
ta ined in Taxpa yerʼ s tax retu rns . App lic able pr ovisio ns in the New Yo rk Ci ty Admi nist rati ve Code prohi bit the discl osure by DOF of
ta x se cre t inf orm ation.
DOF ha s wri tt en sec ur ity pr oc ed ure s re lating to tra nsm itting inf ormat ion wi th membe rs of th e pu bli c using e-m ail , web si tes, or othe r
inte rn et- base d serv ice, of wh ich the Ta xpa yer and Ta xpa ye rʼs Rep resentati ve may hav e a copy upo n requ est. DOF does not repre -
sen t or pro mise that thes e pro ce dur es ar e ade qu ate to pr eser ve the secre cy of ta x secr et informa tion tran smitt ed in such manne r.
The Ta xpa yer and the Ta xp aye rʼs Re pr ese nta tive her eb y re lea se The City of New Yo rk (“Ci ty”) fro m any and all liab ility , and the Tax -
pay er agre es to indem nify an d hold the Cit y harm less fro m any damage, ari sin g out of the ele ctroni c tra nsmi ttal of inform atio n.
CERTI FICATI ON
Si gnatureof Taxp aye r: ___ ____ _________ _________ ____________ __ _____ Dated: ___MO_____NTH /___DAY_____/_____YEAR___
Si gnat ure of Taxpayerʼs
Represe nta tive: ___ ____ ____ ____ _________ _________ ___ _____________ Dated: ___MO_____NTH /___DAY_____/_____YEAR___
ACKN OW LE DGEMENT OF TAXP AYERʼS SIGNAT URE
On thi s __ __ _ da y of __ ____ ____ __, 20___ _ , befor e me__came_________FI_________RST NAME _________ _________ _________________,LAST NAME
to me kn ow n, who swore that (s) he is the person describe d in the above instrument as the Taxpa yer, and acknowled ged that (s)he ex -
ecuted the ab ove instr um ent.
AFFI X
NO TA RY
SEA L
HE RE
_________ ___ __ __ _____ ___ _____ ____ ____
No tar y Public
Note: If the Taxp ayer or the Taxp ayerʼs Rep resen tative is no t an individual, then the following signatur e format should be used:
Si gnature of Taxp aye r (or Taxpa yerʼs Repr esenta tive): _____ _______ _________ _________ ________
By: _____ __ __ ___ ____ ____ ____ _____PR INT FI RS T AND LAS T NAM E OF SIGNER____ _____ ____ ___ Title: ______ _________ _________ ___________________
Aut h-0505 Re v. 12/01/09
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