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Nebraska Motor Vehicle Power of Attorney Form


Nebraska Motor Vehicle Power of Attorney Form
Nebraska Motor Vehicle Power of Attorney Form
POWER OF ATTORNEY
Revised 8/2013
LICENSEES NAME & ADDRESS
Licensee’s Legal Name Business (DBA) Name
_________________________________________________________ ______________________________________________________________
Street Address Mailing Address (if different than street address)
_________________________________________________________ ______________________________________________________________
City State Zip Code City State Zip Code
_________________________________________________________ ______________________________________________________________
IRP/IFTA Carrier Number:____________________________________
ATTORNEY(S)-IN-FACT NAME AND ADDRESS
(If more than two, see Designation of Attorney-in Fact in the instructions.)
Name Name
____________________________________________________ ___________________________________________________________
Title or Firm Name Title or Firm Name
________________________________________________ ___________________________________________________________
Address (Street or Other Mailing Address) Address (Street or Other Mailing Address)
__________________________________________ ___________________________________________________________
City State Zip Code City State Zip Code
________________________________________________ ___________________________________________________________
Email Address Phone Number Email Address Phone Number
The licensee hereby appoints the above named individual(s) or firm as the attorney(s)-in-fact for purposes of duly authorized
representation in proceedings with the Nebraska Department of Motor Vehicles (NEDMV) with respect to the NEDMV matters and
time periods indicated below:
Motor Vehicles Matter of Representation Time Period
Authorized Acts. The attorney(s)-in-fact designated on this form have the authority to perform the following acts with respect to the
designated NEDMV-Motor Carrier Services matters. Please mark the appropriate box. The attorney(s)-in-fact may not do any other
acts unless otherwise marked or specifically noted on the POA:
Fully represent the licensee in any hearing, determination, or appeal.
Enter into any agreements, compromises, stipulations, or settlements on behalf of the licensee with the NEDMV.
Execute waivers, including offers of waivers of collection of taxes or fee deficiencies.
Fully represent the licensee in all matters regarding an IRP, IFTA, or UCR audit.
Execute consents extending the statutory period for assessment or collection of taxes, registration fees, or for issuing a notice of
deficiency determination.
Receive all notices, billings, tax returns, or any other correspondence from the NEDMV that may include confidential information or
information covered under the Uniform Motor Vehicle Records Disclosure Act (UMVRDA).
Perform other acts, specifically:__________________________________________________________________________
If signed by a corporate officer, partner, member, LLC manager, or fiduciary on behalf of the licensee, I herby certify that I have the authority to
execute this Power of Attorney on behalf of the licensee:
Sign
Here
Signature Date
Print Name E-mail Address Title, if applicable
Nebraska Motor Vehicle Power of Attorney Form
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