Form AV-59 - Taxpayer Agent Authorization

10 AV - 59 Web 1 - 12 North Carolina Department of Revenue TAXPAYER AGENT AUTHORIZATION For Business Property Tax Listings of Corporations , Partnerships , Limited Liability Companies , and Unincorporated Associations Do not submit Form AV - 59 to NCDOR or to the county tax office unless specifically requested Agent Form AV - 59 must be retained in your office files Taxpayer Owner Name Business Name Address City State Zip Code Authorized Agent Agent’s Name Agent’s Business Name Agent’s Address City State Zip Code Telephone Number Email Address I , the undersigned property owner , do hereby authorize the agent named above to act on my behalf and take all actions necessary for the preparation and submission of my annual business personal property listing form This agent has my authority to request listing period extensions , prepare the listing form , sign the affirmation on my behalf , and submit it to the proper North Carolina county jurisdictions This authorization becomes effective as of the date below , and the authorization remains in force unless I revoke my authority to the agent or subsequently provide my authorization to another agent Written notification of termination of my authority previously given to this agent will be provided upon request I hereby certify that the above information submitted in this form is true and accurate to the best of my knowledge This form may only be signed by a principal officer of the taxpayer Authorized Signature Title Printed Name Date Telephone Number Email AddressPage