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Indiana Department of Revenue
POWER OF ATTORNEY
(Instructions on Back)
1) 2)
Taxpayer(s) Name(s)Indiana Taxpayer Identication Number
Employer Identication Number
Social Security Number
Spouse’s Social Security Number
D\B\A Name(s)
Address
City
StateZip Code
Telephone #
Hereby appoint(s) the following :
3)
Individual Representative NameAdditional Individual Representative Name
AddressAddress
CityStateZip CodeCityStateZip Code
Telephone #Telephone #
4)
Firm/Corp. Name (If applicable)If Firm or Corp. list Representative(s) Name