Authorization Of Power Of Attorney
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WV-2848
West Virginia State Tax Department
Rev. 09/15
Authorization of Power of Attorney
Authorization giving the person you name on this form specified powers to act on your behalf in interacting or communicating with the West Virginia State Tax Department
Type or print the information you provide on this form. Incomplete, faxed, or photocopied forms will be rejected.
1 | PRINCIPAL INFORMATION The business or individual granting the power of attorney
Print Name of Individual or Business
SSN, FEIN, or Tax ID #
Phone #
Print Name of Spouse or Corporate Officer and Title
SSN, FEIN, or Tax ID #
Phone #
Address
City
State
Zip
2 | AGENT INFORMATION The individual(s) receiving the power of attorney
Print Name of Agent
SSN, BAR #, or CAF #
Phone #
Address
City
State
Zip
3 | EXPIRATION The powers granted by this authorization are valid until:
Revoked.
Liability for delinquent tax or taxes listed below is satisfied.
(Month/Day/Year) _____________________
Other (explain) ________________________________________
4 | AUTHORIZATION
4A| DESCRIPTION OF MATTER Description of the limits of the authorization
Type Of Tax | Account #
Month, Quarter, or Year of Return
(Personal Income, Estate, etc)
(Date of Death if Estate Taxes)
4B| ACTS AUTHORIZED Check ONE of the Following:
Full Authority I hereby give the agent named above authorization to act on my behalf in interacting or communicating with the
WV State Tax Department; to receive confidential information concerning me; to extend the period during which I am liable for
assessment/payment of the above listed taxes; to sign and return forms; to make and sign agreements settling matters in dispute; to
assign this Power of Attorney to another person approved by me in writing; and to receive (but not to endorse and cash) any checks
issued by the WV State Tax Department.
Restrictions I hereby give the agent named above authorization to act for me in dealing with the WV State Tax Department with
the following restrictions:
Date
Date
Signature of Principal Individual
Signature of Spouse
(Signature of Corporate Officer if for a business)
(if any returns listed above are joint returns)
5 | WITNESS or NOTARY Check and complete ONLY ONE of the following:
Witness The person(s) signing as/for the taxpayer(s)
Notary The person signing as/for the taxpayer(s)
is/are known to and signed in their presence of the two
appeared this day before a notary public and acknowledged
disinterested witnesses who have signed below:
this power of attorney as a voluntary act and deed:
Signature of Witness | Date
Signature of Witness | Date
Telephone #
Signature of Witness | Date
NOTARY
SEAL
Telephone #
TAX OFFICE USE ONLY:
REJECTED
ATTACHED
NOTED
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