Power Of Attorney And Declaration Of Representative

Power of attorney and declaration of representative for specified matters involving the IRS.

Taxpayer(s) name, identifying number, and address including ZIP code:

Enter the name of the taxpayer(s)

Enter the EIN or SS# of taxpayer(s)

Enter the street address of the taxpayer

Enter the city, state of the taxpayer

hereby appoints (names(s), CAF number(s), address(es), including ZIP code(s), and telephone numbers:

Enter the name of the attorney(s)

Enter the street address of the attorney(s)

Enter the city, state of the attorney(s)

Enter CAF number of attorney(s)

Telephone number of attorney(s)

as attorney(s)-in-fact to represent the taxpayer(s) before any office of the Internal Revenue Service for the following tax matter(s) (specify the type(s) of tax and year(s) or period(s) (date of death if estate tax):

Type of tax: Enter type of tax

Federal tax number: Enter the EIN or SS# of taxpayer(s)

Year(s) or period(s): End years or periods of tax

Date of death if estate tax: If estate, enter year of death

The attorney(s)-in-fact (or either of them) are authorized, subject to revocation, to receive confidential information and to perform and any all acts that the principal(s) can perform with respect to the above specified tax matters (excluding the power to receive refund checks, and the power to sign the return (see regulations section 1.6012-1(a)(5), Returns made by agents), unless specifically granted below.)

Send copies of notice and other written communications addressed to the taxpayer(s) in proceedings involving the tax matters to:

Notices are to be sent to

Taxpayer initial here: _________________ if you are granting the power to receive, but not to endorse or cash, refund checks for the above tax matters to:

Power is granted to

This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the Internal Revenue Service for the same tax matters and years or periods covered by this power of attorney, except the following:

If earlier powers remain effective, list them

Signature of or for taxpayer(s):

(If signed by a corporate officer, partner, or fiduciary on behalf of the taxpayer, I certify that I have the authority to execute this power of attorney on behalf of the taxpayer.)





Date: ___________________________

If the power of attorney is granted to a person other than an attorney, certified public accountant, enrolled agent, or enrolled actuary, the taxpayer(s) signature must be witnesses or notarized below. (The representative must complete Part II. Only representative listed there are recognized to practice before the Internal Revenue Service.

The persons signing as or for the taxpayer(s): (Check and complete one)

______ is/are known to and signed in the presence of the two disinterested witnesses whose signatures appear here:


Signature of Witness

Date: ___________________


Signature of Witness

Date: ___________________

__________ appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.


Witness (Signature of notary)


I declare that I am not currently under suspension or disbarment from practice before the Internal Revenue Service, that I am aware of Treasury Department Circular No. 230 as amended (31 C.F.R. Part 10), Regulations governing the practice of attorneys, certified public accountants, enrolled agents, enrolled actuaries, and others, and that I am one of the following:

1 a member in good standing of the bar of the highest court of the jurisdiction indicated below;

2 duly qualified to practice as a certified public accountant in the jurisdiction indicated below;

3 enrolled as an agent pursuant to the requirements of Treasury Department Circular No. 230;

4 a bona fide officer of the taxpayer organization;

5 a full-time employee of the taxpayer;

6 a member of the taxpayer's immediate family (spouse, parent, child, brother or sister);

7 a fiduciary for the taxpayer;

8 an enrolled actuary (the authority of an enrolled actuary to practice before the Service is limited by section 10.3(d)(1) of Treasury Department Circular No. 230);

9 Commissioners special authorization (see instructions for Part

II, item 9) ___________________________________________;

and that I am authorized to represent the taxpayer identified in Part I for the tax matters there specified.

Designation Jurisdiction Signature Date

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