Form Par 101 - Virginia Power Of Attorney And Declaration Of Representative

LINE 4 Electronic Notices and Communications

I request that representative(s) listed on this form receive copies of e-mail communication. ..................................................................

Note: Copies of e-mail communications will be furnished through US Postal Service mail.

LINE 5 Acts authorized - The representatives are authorized to receive and inspect conﬁ dential tax information and to perform any and

all acts that I (we) can perform with respect to the tax matters described on line 3. The authority does not include the power to receive

refund checks, the power to substitute another representative, the authority to execute a request for a tax return, the power to sign certain

returns, or the power to consent to a disclosure of tax information.

This Power of Attorney and Declaration of Representative revokes all previous Powers of Attorney and Declaration of Representative and

Powers of Attorney and Releases received by the Virginia Department of Taxation for the matters and years or periods covered by this

form, except the following:

(Specify to whom granted, date and address including ZIP code, and attach copies of earlier power(s) and authorizations.)

LINE 6 Signature of taxpayer(s) - If a tax matter concerns a joint return, both husband and wife must sign if joint representation is

requested. If signed by a corporate ofﬁ cer, partner, guardian, tax matters partner, 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.

___________________________________

____________________________________________

_______________________

Signature

Title, if applicable

Date

___________________________________

Print Name

___________________________________

____________________________________________

_______________________

Signature

Title, if applicable

Date

___________________________________

Print Name

LINE 7 - Declaration and Signature of Representative

Declaration of Representative - Under penalties of perjury, I declare that:

 I am authorized to represent the taxpayer(s) identiﬁ ed on line 1 for the tax matter(s) speciﬁ ed on line 3; and

 I am one of the following:

Attorney—a member in good standing of the bar of the highest court of the jurisdiction shown below.

Certiﬁ ed Public Accountant—duly qualiﬁ ed to practice as a certiﬁ ed public accountant in the jurisdiction shown below.

Enrolled Agent—licensed by the Internal Revenue Service to represent taxpayers before the IRS.

Ofﬁ cer—a bona ﬁ de ofﬁ cer of the taxpayer’s organization. Title: _____________________________

Full-Time Employee—a full-time employee of the taxpayer. Title or Position: _____________________________

Family Member—a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister).

Other (explain)

Signature of representative(s) - Each representative must sign and date below.

Designation -

Jurisdiction (state)

Virginia Authorized Agent

Insert above

or Enrollment Card

Signature

Date

Number (If applicable)

letter (a–g)

No. (if applicable)

A -

IF THIS PAR 101 POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE

IS NOT SIGNED AND DATED OR LACKS COMPLETE INFORMATION, IT WILL BE RETURNED.

2601150 (Rev. 05/10)

Form Par 101 - Virginia Power Of Attorney And Declaration Of Representative - 2010 Page 3

Related Articles

Related forms

Related Categories