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Indiana Tax Power of Attorney Form 1


Indiana Tax Power of Attorney Form 1
Indiana Tax Power of Attorney Form 1
Indiana Department of Revenue
POWER OF ATTORNEY
(Instructions on Back)
1) 2)
Taxpayer(s) Name(s) Indiana Taxpayer Identication Number
Employer Identication Number
Social Security Number
Spouse’s Social Security Number
D\B\A Name(s)
Address
City
State Zip Code
Telephone #
Hereby appoint(s) the following :
3)
Individual Representative Name Additional Individual Representative Name
Address Address
City State Zip Code City State Zip Code
Telephone # Telephone #
4)
Firm/Corp. Name (If applicable) If Firm or Corp. list Representative(s) Name
a)
Address
b)
City State Zip Code
c)
Telephone #
d)
5)
Type of Tax Tax Form Number Year(s) / Period(s)
(Income, Withholding, Sales, etc.) (IT-40, WH-3, ST-103, etc.)
____________________________ __________________________ ________________________
____________________________ __________________________ ________________________
____________________________ __________________________ ________________________
6)
I acknowledge that the designated representative has the authority to receive condential information and full power to perform on behalf of
the taxpayer in tax matters related to this Power of Attorney. This authority does not include the power to receive refund checks.
I acknowledge that actions taken by the designated representative are binding, even if the representative is not an attorney. Proceedings can-
not later be declared legally defective because the representative was not an attorney.
If I am a corporate ofcer, partner or duciary acting on behalf of the taxpayer, I certify that I have authority to execute this Power of Attorney
on behalf of the taxpayer.
7)
Signature _________________________________________________ Date _______________________________
Printed Name ______________________________________________
Title _____________________________________________________ Telephone # _________________________
POA - 1
State Form 49357
(R2 / 9-09)
Indiana Tax Power of Attorney Form 1
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