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Connecticut Tax Power of Attorney Form

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Connecticut Tax Power of Attorney Form
Connecticut Tax Power of Attorney Form
Power of Attorney
Taxpayer’s Name Social Security Number
Spouse’s Name (Personal income tax or individual use tax only) Social Security Number
Mailing Address Connecticut Tax Registration Number
City State ZIP Code Federal Employer Identi cation Number
Department of Revenue Services
State of Connecticut
25 Sigourney Street
Hartford CT 06106-5032
(Rev. 07/08)
Part I: Taxpayer(s) Giving a Power of Attorney to Another Person
Taxpayer is: (Check box)
Corporation Partnership Sole Proprietorship Trust (other than a business trust) Estate
Individual Limited Liability Company Business Trust Other (specify) ____________________________________
Part II: Declaration of Person(s) Giving Power of Attorney and Powers Given
The taxpayer(s) named above appoints the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before DRS and receive
tax returns and return information for the following tax matters. Specify all tax types and periods affected by this power of attorney with the
understanding that this authority applies only to the tax types and periods listed below. Enter the date of death for succession and estate taxes.
Indicate the representative to whom a copy of any notice from DRS should be sent by checking the box below. Check one box only.
See instructions for who may execute this power of attorney. This power of attorney revokes all previous powers of attorney on le with
the Department of Revenue Services (DRS) for the same tax matters and years or periods covered by this power of attorney.
Any of the attorney(s)-in-fact are authorized, subject to revocation, to receive tax returns and tax return information as de ned in Conn.
Gen. Stat. §12-15, and to perform on behalf of the taxpayer(s) the following acts for the tax matters described below. The authority does
not include the power to sign certain returns unless speci cally stated below.
Check the boxes for the powers given to:
Print Name: ____________________________________________________________ Title: __________________________________________
Signature: _____________________________________________________________ Date: __________________________________________
Part III: Power of Attorney Given To
Name Address Check One Box Telephone Number
Tax Type (Sales Tax, Gift Tax, etc.) Year(s) or Period(s)
Receive, but not to endorse and collect, checks (made payable to the taxpayer mentioned above) in payment of any refund of
Connecticut taxes, penalties, or interest.
Execute waivers (including offers of waivers) of restrictions on assessment or collection of de ciencies in tax and waivers of notice
of disallowance of a claim for credit or refund.
Execute or terminate consents extending the statutory period for assessment or collection of tax.
Execute closing agreements under Conn. Gen. Stat. §12-2e.
Delegate authority or to substitute another representative.
Represent the taxpayer(s) named above before DRS.
Sign returns. (See instructions.)
Declaration: I am the taxpayer identi ed in Part I, or if I am not the taxpayer identi ed in Part I, I have been authorized by the taxpayer to execute
this power of attorney on behalf of the taxpayer and I am permitted by the instructions on this Form LGL-001 to execute this power of attorney.
I declare under penalty of law that I have examined this document (including any accompanying schedules and statements) and, to the best of
my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a
ne of not more than $5,000, or imprisonment for not more than ve years, or both.
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Connecticut Tax Power of Attorney Form