AUTHORIZATION TO DISCLOSE TAX INFORMATION
                             & DESIGNATION OF REPRESENTATIVE
                             OFFICE OF STATE TAX COMMISSIONER
                             SFN 28258 (4-2020)                                                                                Form 500
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                                                      City                          State             ZIP Code

Email Address                                                                                      Fax Number

Designated Individual or Firm
Name of Individual (or Firm)                                                      Telephone Number Social Security Number or FEIN Number

Mailing Address                                                      City                          State             ZIP Code

Email Address                                                                                      Fax Number

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        For Office Use Only
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.