Power of Attorney and Declaration of Representative

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

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

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: _________________
Federal tax number: __________
Year(s) or period(s) _________
Date of death if estate tax: _____

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: 
the appointee first named above

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: 
the appointee first named above

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: 
__________________________________________________________________

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.) 

________________________________________________ 
Signature 

________________________________________________ 
Title 

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) 

PART II 
I declare that I am not currently under suspension or disbarment form 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 

Power of Attorney and Declaration of Representative
Review List

This review list is provided to inform you about this document in question and assist you in its preparation.  This document is required for the Internal Revenue Service, should you want someone properly qualified to represent you at any meetings with them.  A qualified representative will furnish you with the latest IRS document.  This is representative of the information that must be provided.