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Indiana Department of Revenue
POWER OF ATTORNEY
(Instructions on Back)
Taxpayer(s) Name(s)Indiana Taxpayer Identication Number
Employer Identication Number
Social Security Number
Spouse’s Social Security Number
Hereby appoint(s) the following :
Individual Representative NameAdditional Individual Representative Name
CityStateZip CodeCityStateZip Code
Telephone #Telephone #
Firm/Corp. Name (If applicable)If Firm or Corp. list Representative(s) Name
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