State Form 23261 (R8/4-16) - Power Of Attorney Form

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POWER OF ATTORNEY
State Form 23261 (R8 / 4-16)
Prescribed by the Department of Local Government Finance
Please TYPE or PRINT.
Powers of attorney are governed by Indiana Code 30-5. Certified tax representatives are governed by 50 IAC 15-5. Taxpayers are strongly encouraged to
review the applicable laws before creating a power of attorney.
PART I - POWER OF ATTORNEY
1. Taxpayer Information (Taxpayer must sign and date this form on page 2, section 7, and have the form notarized on page 2, section 8.)
Name of taxpayer(s)
Address(es) of taxpayer(s) (number and street, city, state, and ZIP code)
Last four digits of Social Security Number (optional)
Employer identification number (optional)
Telephone number
(
)
X X X - X X - ________________
The above named taxpayer does hereby appoint the following representative(s) as attorney(s) in fact:
2. Representative Information (Representative must sign and date this form on page 2, Part II.)
Name of representative
Address of representative (number and street, city, state, and ZIP code)
Telephone number
Fax number
Check if:
(
)
(
)
New address
New telephone number
Name of representative
Address of representative (number and street, city, state, and ZIP code)
Telephone number
Fax number
Check if:
(
)
(
)
New address
New telephone number
to represent the taxpayer(s) for the following matters before the:
Department of Local Government Finance
Indiana Board of Tax Review
_____________ County Property Tax Assessment Board of Appeals
3. Tax Matters
Type of Tax (real property, personal property)
Tax Form Number (130,131,133,17T, etc.)
Year(s) or Period(s)
Expiration date of this power of attorney (month, day, year)
Check this box if the representative is authorized to represent the
(Optional, but recommended; this section to be completed by taxpayer.)
taxpayer regarding all tax forms for all years or periods.
4. Acts Authorized:
The representative(s) is/are authorized to receive and inspect confidential tax information and to perform any and all acts that I (we) can perform with
respect to the tax matters described in section 3, including the authority to sign any agreements, consents, or other documents.
List any specific additions or deletions to the acts otherwise authorized in this power of attorney
5. Notices, Communications, and Refund Checks:
Notices and other communications will be sent to the first representative listed in section 2.
If you also want the second representative listed to receive such notices and communications, check this box.
State the address to which any refund checks should be mailed (number and street, city, state, and ZIP code):
_________________________________________________________________________________________________________________________
Please note that by statute, refunds are issued to the party that paid the taxes.
6. Retention / Revocation of Prior Power(s) of Attorney:
The filing of this power of attorney automatically revokes all earlier power(s) of attorney with the ___________________ County Property Tax Assessment Board
of Appeals, Department of Local Government Finance, or Indiana Board of Tax Review 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 this box.
You must attach a copy of any power of attorney you wish to remain in effect.
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