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Kentucky Tax Power of Attorney Form


Kentucky Tax Power of Attorney Form
Kentucky Tax Power of Attorney Form
12A201 (8-94)
Commonwealth of Kentucky
REVENUE CABINET
POWER OF ATTORNEYEY (POA)
FOR KENTUCKY TAX MATTERS
Register New
POA
POA Address Change
Renew POA
Cancel POA
For Revenue Use Only;
Taxpayer's Social Sec
urity No(s).
1. Taxpayer(s) Name(s) (Print/Type)
SSN Revenue File No _____________
SSN
Receipt Date ________________
Address
Business Taxpayer's Federal
Revocation Date _____________
FEIN
---
Expiration Date ______________
City, State and
ZIP Code
Taxpayer's Daytime Telephone No
( ) ---
hereby appoint(s) the following individual(s):
2.
Power of Attorney Name{s) and SSN or FEIN
Address
Telephone Number
(
0
)
POA Name (Print/Type) SSN/FEIN City State ZIP Code
( ) -
POA Name (Print/Type) SSN/FEIW City State ZIP Code
( ) -
POA Name (Print/Type) SSN/FEIN City State ZIP Code
as an agent to represent the taxpayer(s) before any office of the Kentucky Revenue Cabinet (KRC) for the following tax matter(s).
Type of tax must be specified. Tax years or periods are optional except for inheritance tax Date of death must be reported for inheritance
tax matters. If this case is assigned to the KRC'.s Division of Collections, specify the Collection Case Number fry appropriate block.
(Required)
Type of tax and account number
(Individual, corporate, sales and use, etc.)
(Optional)
Tax year(s) or period(s)
mm/dd/yy—mm/dd/yy
Required only if information to be disclosed is limited to specific tax periods
Tax
Type/Account No
Tax Type/Account Na
1.
Individual Income
2. 1. 2.
3. 4. 3. 4.
For Collection Cases
Collection Case Number(s)
The agent is authorized, subject to revocation by the taxpayer, to receive confidential information and to perform any and all acts that
he taxpayer can perform regarding the above specified tax matters (excluding the power to receive refund chocks). List any POA limita
tions below. Indicate if you are granting the agent the power to sign the return.
The agent is authorized, subject to revocation by the taxpayer, to receive confidential information and to perform any and all acts that
the taxpayer can perform regarding the above specified tax matters (excluding the power to receive refund chocks). List any POA limita-
tions below. Indicate if you are granting the agent the power to sign the return.
Send
originals
of all notices and all other written communications in proceedings involving the above tax matters to the representative
or agent first named above, and a duplicate copy of all notices and an all other written communications to the taxpayer named above, or
Send
copies
of all notices and all other written communications that are addressed to the taxpayer(s) regarding the above tax matters
to:
1. the representative or agent first named above, or
2. names of not more than two of the representatives or agents named above.
This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the Kentucky Revenue Cabinet
for the same tax matters and years or periods covered by this power of attorney, except the fallowing:___________________________
(Specify exceptions and to whom granted, date and address.)
X
Taxpayer(s) Signature
Title (if applicable)
Date
Kentucky Tax Power of Attorney Form