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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 Identiﬁ cation Number
Department of Revenue Services
State of Connecticut
25 Sigourney Street
Hartford CT 06106-5032
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 ﬁ 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 deﬁ 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 speciﬁ cally stated below.
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