Revised 10/26/2018
1. Name of taxpayer( as distinguished from trade name
2.Federal employer identification number
3. Trade name (if any)
4. Address (Street number, street name and suite or room number) 5.Other identification number
6. City 7. State 8. ZIP code
9. Contact person 10. Daytime telephone number
12. Name (enter company name or name of business
13.Federal employer identification number
14. Address (Street number, street name and suite or room number)
16. State 17. ZIP code
18. Contact person 19. Daytime telephone number
Authorization of Reporting Agent to Sign and File Returns (Caution: See Authorization Agreement)
21.
EL-941
Forms W-2
Authorization of Reporting Agent to Make Deposits and Payments (Caution: See Authorization Agreement)
22.
EL-501 EL-941
Disclosure of information to Reporting Agents
23a.
23b.
Check here if the reporting agent also wants to receive copies of notices from the city income tax department ....……........................................
24.
year forms beginning
I certify I have the authority to execute this form and authorize disclosure of otherwise confidential information on behalf of the taxpayer.
12. Sign your name here 13. Print your title here
14. Print your name here 15. Date (MM/DD/YYYY) 16. Best daytime phone number
I understand that this agreement does not relieve me, as the taxpayer, of the responsibility to ensure that all tax returns are filed and that all deposits and
payments are made. If line 21 is completed, the reporting agent named above is authorized to sign and file the return indicated, beginning with the quarte
r
or
year indicated. If any starting dates on line 22 are completed, the reporting agent named above is authorized to make deposits and payments beginning
with the period indicated. Any authorization granted remains in effect until it is revoked by the taxpayer or reporting agent. I am authorizing the income tax
department of the above names city to disclose otherwise confidential tax information to the reporting ag
ent relating to the authority granted on line 21
an
d/or line 22, including disclosures required to process Form EL-8655. Disclosure authority is effective upon signature of taxpayer and receipt of Form
8655 by the income tax department of the above named city. The authority granted on Form 8655 will not revoke any Power of Attorney (Form EL-2848) in
effect.
Sign
Here
Check here to authorize the reporting agent to receive or request copies of tax information and other communications from the income tax
department of the above named city related to the authorization granted on lines 21, 22, and/or line 24 ................................................................
Use the entry lines below to indicate the tax return(s) to be filed by the reporting agent. Enter the beginning year of annual tax
returns or beginning
qu
arter of quarterly tax returns. See the instructions for how to enter the quarter and year. Once this authority is granted, it is effective until revoked
by the taxpayer or reporting agent.
Use the entry lines below to enter the starting date (the first month and year) of any tax return(s) for which the reporting agent is authorized to make
deposits or payments. See the instructions for how to enter the
month and year. Once this authority is granted, it is effective until revoked by the
ta
xpayer or reporting agent
The reporting agent is authorized to receive otherwise confidential taxpayer information from the income tax department of the city named
above to assist in responding to certain notices relating to the Form W-2 series information returns. This authority is effective for calendar
City of East Lansing
PLEASE T
OR PRINT
INCOME TAX DEPARTMENT
PLEASE T
OR PRINT
Reporting Agent Authorization
