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.

Form 500 Instructions
SFN 28258 (4-2020)

General Instructions                       Specific Instructions                       State Tax Commissioner, and to authorize 
                                                                                       the Office of State Tax Commissioner to 
                                           Taxpayer Information
Form 500 may be used by a taxpayer to                                                  disclose confidential tax information to 
do one of the following:                   Enter the taxpayer’s name, social security  the designated individual or firm.
                                           number or federal employer identification 
 Authorize the North Dakota Office                                                    Box C - Check this box to authorize the 
                                           number (FEIN), mailing address, and 
  of State Tax Commissioner to                                                         Office of State Tax Commissioner to 
                                           contact information.
  disclose the taxpayer’s confidential                                                 send confidential tax information to the 
  tax information to another individual    For a trust, enter the trust’s name and     designated individual or firm by facsimile 
  or firm not otherwise entitled to the    FEIN, and the name, mailing address, and    (fax) transmission or email.
  information.                             contact information of the fiduciary.
                                                                                       Box D - Check this box to revoke all 
 Designate another individual or          For an estate, enter the decedent’s name    previously filed Forms 500. To limit 
  firm to represent or act on behalf       and social security number, and the name,   the revocation to a specific designated 
  of the taxpayer before the Office        mailing address, and contact information    individual or firm, identify that individual 
  of State Tax Commissioner, and to        of the decedent’s personal representative   or firm by completing the “Designated 
  authorize the North Dakota Office        or fiduciary.                               Individual or Firm” section of the form. 
  of State Tax Commissioner to                                                         Otherwise, leave that section of the 
                                           Designated Individual or Firm
  disclose the taxpayer’s confidential                                                 form blank to apply the revocation to all 
  tax information to the designated        Enter the name, social security number or   previously designated individuals and 
  representative or firm.                  federal employer identification number      firms. If checking this box, do not check 
                                           (FEIN), mailing address, and contact        any of the other boxes (A, B, or C) on the 
Form 500 does not apply to the routine 
                                           information for the designated individual   form.
mailing of tax forms, refund checks, 
                                           or firm. If designating more than one 
original notices (e.g., a Notice of                                                    Signature of Taxpayer(s)
                                           individual or firm, attach a statement 
Determination), or other original written 
                                           listing each one.                           Partnership (all types). One of the general 
communications, which are always mailed 
                                                                                       partners must sign.
to the taxpayer.                           Note: Do not complete this section of 
                                           the form if filing this form to revoke      Corporation. An officer having authority 
Unless Box C on Form 500 is checked 
                                           previously filed Forms 500 and the          to bind the corporation must sign.
to authorize the sending of confidential 
                                           revocation is intended to apply to all 
tax information by facsimile (fax)                                                     Limited liability company. A governor or 
                                           previously designated individuals and 
transmission or email, the Office of State                                             manager must sign.
                                           firms.
Tax Commissioner will send confidential 
                                                                                       Estate, trust, or any other situation where 
tax information authorized by Form 500     Authorization or Revocation
                                                                                       there is a fiduciary relationship. The 
to the designated individual or firm only 
                                           For Box A and Box B, the authorization      personal representative, trustee, guardian, 
by letter or telephone.
                                           to disclose or the designation of           conservator, or other fiduciary must sign.
Changing a previously filed Form 500.      representative can be limited to a certain 
To change a Form 500 previously filed      tax type (e.g., individual income tax or    Where to Send Form 500
with respect to a particular designated    sales tax), form number, or taxable year or 
individual or firm, complete and file      period by entering that information in the  Form 500 may be submitted to the North 
a new Form 500 for that designated         spaces provided.                            Dakota Office of State Tax Commissioner 
individual or firm. The new Form 500                                                   by fax, email, or regular mail.
                                           If attaching a statement to identify 
automatically revokes and replaces the 
                                           additional designated individuals or firms, Fax or email
previously filed Form(s) 500.
                                           indicate the authority being given to each  Income & Withholding Taxes—
Revoking a previously filed Form 500.      one by entering “Box A” or “Box B” (and       Fax                       701.328.1942
To revoke a previously filed Form 500,     “Box C” if desired) next to each one listed   Email            individualtax@nd.gov
see instructions to Box D under            on the statement.
                                                                                       Business Registration—
“Authorization or Revocation.”
                                           Box A -  Check this box to authorize the      Fax                       701.328.0332
When Form 500 takes effect. Form 500       Office of State Tax Commissioner to           Email     taxregistration@nd.gov
takes effect upon receipt by the Office of disclose confidential tax information to 
                                                                                       General (other tax or purpose)—
State Tax Commissioner and remains in      the designated individual or firm.
                                                                                         Fax                       701.328.3700
effect until revoked by the taxpayer.
                                           Box B -  Check this box to designate an       Email               taxinfo@nd.gov
                                           individual or firm to represent or act on 
                                                                                       Regular mail
                                           behalf of the taxpayer before the Office of 
                                                                                         Office of State Tax Commissioner
                                                                                         600 E. Boulevard Ave., Dept. 127           
                                                                                         Bismarck, ND 58505-0599