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Texas Crude Oil and Natural Gas Tax Limited Power of Attorney Form


Texas Crude Oil and Natural Gas Tax Limited Power of Attorney Form
Texas Crude Oil and Natural Gas Tax Limited Power of Attorney Form
Form 10-341 (12-07)
STATE OF TEXAS §
§
COUNTY OF __________________ §
CRUDE OIL AND NATURAL GAS TAX
LIMITED POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENT that I, ______________________________ (Taxpayer)
of ____________________________________ (Company name), hereby make, constitute, and appoint
_________________________ (Taxpayer representative), as my true and lawful attorney in fact for me
and in my name, place and stead; for the following purposes only:
To seek a refund of Texas Crude Oil and/or Natural Gas taxes for the periods of _____________ through
______________ . This includes the right to request and receive any documentation on file with the
Comptroller of Public Accounts in order to prove my right to a refund, to amend and sign any tax report(s)
originally filed during these time periods, to sign transfer forms, and to receive any and all information
pertaining to my refund request. Modes of communication for requesting and receiving information may
include telephone, e-mail, fax or mail.
Check all that apply:
Allow to file tax reports and access account data for Crude Oil Tax for the tax periods of
_______________ through _______________ . The date range begins with the signature date
indicated below through _______________ .
Allow to file tax reports and access account data for Natural Gas Tax for the tax periods of
_______________ through _______________ . The date range begins with the signature date
indicated below through _______________ .
This Crude Oil and Natural Gas Tax Limited Power of Attorney is effective no longer than one year
from the signature date.
Dated this ______________ day of __________________,_________ .
TAXPAYER REPRESENTATIVE INFORMATION TAXPAYER INFORMATION
______________________________________ _______________________________________
11-digit Texas taxpayer number (if assigned) Print name
______________________________________ _______________________________________
Taxpayer representative name (Print) Signature
______________________________________ _______________________________________
Mailing address Relationship to entity (i.e., President, Treasurer)
______________________________________ _______________________________________
City, State, ZIP code 11-digit Texas taxpayer number
______________________________________ _______________________________________
Daytime phone (Area code and number) Daytime phone (Area code and number)
You have certain rights under Chapters 552 and 559, Government Code, to review, request, and correct
information we have on file about you. To request information for review or to request error correction, contact us at the toll-free number listed on this form.
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Texas Crude Oil and Natural Gas Tax Limited Power of Attorney Form