Rev184 - Power Of Attorney ( Minnesota Department Of Revenue)
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2REV184
Power of Attorney
Read the instructions on the back before completing this form.
Your name or name of entity
Social Security or MN tax ID number (or federal ID number)
Spouse’s name, if joint
Spouse’s Social Security number (if a joint return)
(or corporate officer, partner or fiduciary if a business)
Street address
Check one
(see instructions):
Original—your first power of
attorney authorizing this appointee
City
State
Zip code
Amend—changes an existing power
of attorney for this appointee
Expiration date
Month
Day
Year
Cancel/Revoke—cancels a
(If a date is not provided, this power
of attorney is valid until revoked.)
previously filed power of attorney
I appoint the following as attorney-in-fact to represent me before the Minnesota Department of Revenue. The appointee is
authorized to provide and receive private and nonpublic information concerning my state taxes, and to perform any and all
acts that I can perform with respect to my tax matters, unless noted below.
Name of person (appointee) given power of attorney
Name of firm (if applicable)
Street address
City
State
Zip code
Phone number
FAX number
(
)
(
)
Unless limitations are noted below, the appointee is authorized to perform any and all acts that you can perform with
respect to your tax matters, including the authority to sign tax returns. If you want to limit the appointee’s authority to
specific tax types, periods and/or duties, you must indicate the types of authority below.
To grant limited authority: Check only the boxes that apply. By checking the boxes, the appointee will be authorized to
perform acts on your behalf with respect to only the indicated tax matters:
Tax type
Year(s) or period(s)
Tax type
Year(s) or period(s)
Individual income tax
Sales and use tax
Property tax refund
Withholding tax
Partnership tax
S corporation tax
MinnesotaCare taxes
Corporation franchise
Fiduciary income tax
Other (please specify):
If the appointee is not authorized to sign the return(s) for the above tax matters, check this box:
Comments:
The power of attorney is not valid until it is signed and dated.
Your signature or signature of corporate officer, partner or fiduciary
Print your name (and title, if applicable)
Date
Phone
(
)
Spouse’s signature (if joint)
Print spouse’s name (if joint)
Date
Phone
(
)
Mail to: Minnesota Revenue, Mail Station 4123, St. Paul, MN 55146-4123
(Rev. 5/05)
Stock No. 6000184
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