Gen 58 Revised 11-03 - North Carolina Department Of Revenue Page 2
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AV-63
Web-Fill
10-14
4 Retention/Revocation of Prior Power(s) of Attorney. - The filing of this power of attorney automatically revokes all earlier power(s) of
attorney on file with the Property Tax Commission for the same tax matters and years or periods covered by this document. If you do not
want to revoke a prior power of attorney, check here ................................................................................................................................................
YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.
5 Signature of Taxpayer(s). - I certify that I have the authority to execute this form on behalf of the taxpayer.
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
Signature
Date
Title (if applicable)
Print Name
Signature
Date
Title (if applicable)
Print Name
_____________________________________________________________________________________County, North Carolina
Signed and sworn to before me this day by_____________________________________________________________________
Date:__________________
_____________________________________________________________________
Official Signature of Notary
_____________________________________________________________________
Notary’s printed or typed name, Notary Public
(Official Seal)
My commission expires: _________________________________________________
Part 2.
Declaration of Nonattorney Representative
Under penalties of perjury, I declare that:
I am authorized to represent the taxpayer(s) identified in Part 1 for the tax matter(s) specified there; and
I am one of the following:
a Officer;
b Manager or member-manager, if the business entity is a limited liability company;
c Employee whose income is reported on IRS Form W-2, if the business entity authorizes the representation in writing; or
d Owner of the business entity, if the business entity authorizes the representation in writing and if the owner’s interest in the business
entity is at least twenty-five percent (25%).
IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE RETURNED.
Designation - Insert
Signature
Date
above letter (a-d)
_____________________________________________________________________________________County, North Carolina
Signed and sworn to before me this day by_____________________________________________________________________
Date:__________________
_____________________________________________________________________
Official Signature of Notary
_____________________________________________________________________
Notary’s printed or typed name, Notary Public
(Official Seal)
My commission expires: _________________________________________________
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