State Form 23261 (R8/4-16) - Power Of Attorney Form Page 2

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7. Signature of Taxpayer:

If signed by a corporate officer, partner, guardian, tax matters partner/person, executor, receiver, administrator or trustee on behalf of the taxpayer,

I certify that I have the authority to execute this form on behalf of the taxpayer.

The following applies if the authorized representative is a Certified Property Tax Representative pursuant to 50 IAC 15-5-5:

I understand that by authorizing ____________________________ to serve as my Certified Property Tax Representative,

I am aware of and accept the possibility that the property value may increase as a result of filing an administrative appeal

with the Property Tax Assessment Board of Appeals, and that I may be compelled to appear at a hearing before the

Property Tax Assessment Board of Appeals or the Department of Local Government Finance.

I further understand that the Certified Property Tax Representative is not an attorney and may not present arguments of a

legal nature on my behalf.

Unless otherwise stated on this line, this power of attorney is effective upon the date of my signature. ________________________________________

If this power of attorney is not signed, dated and notarized, it will be returned.

Signature of taxpayer

Date of signature (month, day, year)

Printed name of taxpayer

Title (if applicable)

Signature of taxpayer

Date of signature (month, day, year)

Printed name of taxpayer

Title (if applicable)

8. Notarization

STATE OF ___________________________________________________

SS:

COUNTY OF _________________________________________________

Before me, a notary public in and for said state and county, personally appeared, this ______ day of ____________________________, ____________,

the taxpayer(s) or a person duly authorized to sign for and on behalf of the taxpayer(s), who acknowledged the execution of this Power of Attorney as the

voluntary act and deed of the taxpayer(s).

Signature of notary public

County of residence

Typed or printed name of notary public

Date commission expires (month, day, year)

PART II - DECLARATION OF REPRESENTATIVE

Under penalties of perjury, I declare that:

I am aware of the statutes, rules and regulations applicable to the matters specified in section 3;

I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there; and

I am one of the following:

a. A Certified Public Accountant - duly qualified to practice as a certified public accountant in the jurisdiction shown below.

(Note that a Certified Public Accountant who is not also a Certified Tax Representative may only represent a client in a matter that relates to