Indiana Department Of Revenue Power Of Attorney
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POA - 1
INDIANA DEPARTMENT OF REVENUE
Rev. 12/02
POWER OF ATTORNEY
SF 49357
(Instructions on Back)
1)
Taxpayer(s) Name(s)
2)
Indiana Taxpayer Identification Number
DBA Name(s)
Employer Identification Number
Address
Social Security Number
City
State
Zip Code
Spouse's Social Security Number
(
)
Telephone #
3)
Hereby appoint(s) the following : (If Firm or Corp, give Representative(s) Name)
Firm/Corp/Individual Name
FID, TID, PTIN or SSN
Address
Representative(s)
City
State
Zip Code
(
)
Telephone #
Firm/Corp/Individual Name
Representative(s)
Address
City
State
Zip Code
(
)
Telephone #
Type of Tax
Year(s) / Period(s)
4)
____________________________
_________________________________
____________________________
_________________________________
____________________________
_________________________________
5)
Said attorney(s) -in-fact shall (subject to revocation) have authority to receive confidential information and full power to
perform on behalf of the undersigned all acts incidental to such representation:
If signed by the Corporate Officer, Partners, or Fiduciary on behalf of the taxpayer, I certify that I have authority to execute this
Power of Attorney on behalf of the taxpayer.
Signature
Date
(
)
Title
Telephone #
6)
Subscribed and sworn to before me on this
day of
,
.
Year
My Commission Expires
Notary Public
County
Reset
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