Authorization/Cancellation Request - Signature Form

Taxpayer Information
SIN:*
Given Name:*
Surname:*
Representative Information
Rep ID:
Group ID*
Business Number:*
Name
First Last
Group Name:*
Business Name:*
Phone
Authorization Information
Level of Authorization
Expiry Date, if applicable:
Cancellation Information
Tick the appropriate box.
- Cancel ALL Representatives
- Cancel the Representative listed Below
Rep. ID
Group ID
Business Number:
Name
First Last
Business Name:
Signature Information
Legal
- I am the Legal Representative for this Taxpayer
Name of taxpayer or legal representative
Phone
Certification
By signing and dating this page, you authorize the Canada Revenue Agency to interact with and/or cancel the representative(s) mentioned above.
Signature of taxpayer or legal representative
Date
Signature Page

Taxpayer Information