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Get Canada AT4930 2012

ALBERTA CONSENT FORM Tax and Revenue Administration This form authorizes Tax and Revenue Administration to release confidential taxpayer information to a designated third party representative in matters pertaining to applicable legislation. Note This authorization is valid until the taxpayer or authorized signing person of the taxpayer cancels it in writing. Please complete a separate form for each representative. Send the completed form to TAX AND REVENUE ADMINISTRATION 9811 109 STREET EDMONTON AB T5K 2L5 or fax to 780-427-0348. If you have any questions please phone 780-427-3044. If calling long distance within Alberta call 310-0000 then enter 780-427-3044. The purpose of this form is To authorize a third party representative to receive taxpayer information or To cancel a third party representative from receiving taxpayer information 1. Taxpayer Identification Corporate Legal Name Alberta Corporate Account Number CAN Alberta Business Identification Number BIN 2. Authorized Third Party Identification Authorized Individuals Name and/or Name of the Firm Phone Number Address 3. Details of Authorization All Tax Programs Indicate the period for which authorization or cancellation applies OR All Years Corporate Income Tax Tourism Levy Specific Years International Fuel Tax Agreement IFTA Tax Exempt Fuel Users TEFU Prescribed Rebate Offroad Percentages PROP All Years Prior to Other specify 4. Authorized Signature authorized signing officer of the taxpayer Name Date Signed please print Signature Postion Office or Rank This form must be signed by an authorized person of the business such as a director of the corporation* This form will be considered invalid if incomplete or not signed and dated by an authorized person of the business. Please complete a separate form for each representative. Send the completed form to TAX AND REVENUE ADMINISTRATION 9811 109 STREET EDMONTON AB T5K 2L5 or fax to 780-427-0348. If you have any questions please phone 780-427-3044. If calling long distance within Alberta call 310-0000 then enter 780-427-3044. If you have any questions please phone 780-427-3044. If calling long distance within Alberta call 310-0000 then enter 780-427-3044. The purpose of this form is To authorize a third party representative to receive taxpayer information or To cancel a third party representative from receiving taxpayer information 1. The purpose of this form is To authorize a third party representative to receive taxpayer information or To cancel a third party representative from receiving taxpayer information 1. Taxpayer Identification Corporate Legal Name Alberta Corporate Account Number CAN Alberta Business Identification Number BIN 2. Taxpayer Identification Corporate Legal Name Alberta Corporate Account Number CAN Alberta Business Identification Number BIN 2. Authorized Third Party Identification Authorized Individuals Name and/or Name of the Firm Phone Number Address 3. Authorized Third Party Identification Authorized Individuals Name and/or Name of the Firm Phone Number Address 3. Details of Authorization All Tax Programs Indicate the period for which authorization or cancellation applies OR All Years Corporate Income Tax Tourism Levy Specific Years International Fuel Tax Agreement IFTA Tax Exempt Fuel Users TEFU Prescribed Rebate Offroad Percentages PROP All Years Prior to Other specify 4. .

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