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If rm or vendor, list representative(s) name, telephone number and email.
Representative(s) NameTelephone NumberEmail
5. General Authorization
☐ I authorize the listed representative(s), in addition to anything otherwise authorized on this form, to represent me regarding any
matters with the Indiana Department of Revenue regardless of tax years or income periods. I understand that this authority will expire 5
years from the date this POA is signed or a written and signed notice is filed revoking this authorization.
6. Tax Type(s) (Not applicable if box is checked in question 5 above)
Type of Tax Year(s)/Period(s)
(Income, Withholding, Sales, etc.) ☐ Current Year ☐ Specify
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