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Revenue Tax and License SecrecyClause
Washington State
Confidentiality Agreement
This form must be completed and signed by individuals with access to Confidential Information in the custody and
control of the Department of Revenue, and approved by the appropriate designated authority.
Identification: Name: BRIAN CARLSON
Employer: KITTITAS COUNTY
Address: 205 W. 5th Ave
City, State, Zip: Ellensburg WA 98926
Title: BUDGET & FINANCE DIRECTOR
Phone: (509) 962-7502
Email: brian.carlson@co.kittitas.wa.us
Scope: Department of Revenue Confidential Information covered by this agreement includes:
• Licensing information (RCW 19.02.115)
• Personally identifying information (RCW 42.56.590)
• Property tax information (RCW 84.08.210, RCW 84.40.020, RCW 84.40.340)
• Tax information (RCW 82.32.330)
• Federal tax information (26 USC 6103)
• Unclaimed Property (RCW 63.29.380)
• Confidential organizational and other information exempt by law
Acknowledgement of Confidentiality: I have read and understand the following obligations and responsibilities:
hr Ij may use and access Confidential Information for official purposes only as needed to conduct business
r�m-M,) and if applicable, as authorized by the data sharing agreement with my employer.
I may not use, publish, transfer, sell or otherwise disclose any Confidential Information acquired for any
unauthorized purpose.
must protect the information and maintain required security safeguards.
l must maintain confidentiality after I no longer have access to the information.
An individual who discloses confidential tax or licensing information to an unauthorized person is guilty of
a misdemeanor, A state employee is subject to loss of position and inability to hold public employment in
Washington State for two years. Additional penalties may apply under state or federal laws. See RCW
82.32.330(6) and 19.02.115(5)
1 certify under penalty of perjury_"r the laws of the state of Washington that the foregoing is true and correct.
Signature: Date Signed: 3 An/
Authorization (to be completed by employer):
I authorize the individual above to have access to Department of Revenue Confidential Information to meet the
following business requirements:
Name: Title:cl.�
Signature: Date: 5.11d
Authority:.. Supervisor i Contract Manager ❑Agency Security Administrator El Other:
For tax assistance or to request this document in an alternate format, please call 360-705-6705. Teletype (TTY) users may use the Washington Relay
Service by calling 711
REV 10 0032e (6/25/19)