Employer Tax Form Packet (Page 8 of 9) in pdf

Employer Tax Form Packet Page 8

If the power of attorney is granted to a person other than an attorney, certified public accountant, public accountant or enrolled agent, the taxpayer(s)

signature must be witnessed or notarized below.

The person(s) signing as or for the taxpayer(s) (check and complete one):

is/are known to and signed in the presence of the two disinterested witnesses whose signatures appear here:

Signature of witness

Date

Signature of witness

Date

appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.

Signature of notary

Date

Part 2. Declaration of Representative.

All representatives must complete this section.

I declare that I am not currently under suspension or disbarment from practice within the Commonwealth or in any jurisdiction, that I am aware of regula-

tions governing the practice of attorneys, certified public accountants, public accountants, enrolled agents and others, and that I am one of the following:

1 a member in good standing of the bar of the highest court of the jurisdiction shown below;

2 duly qualified to practice as a certified public accountant or public accountant in the jurisdiction shown below;

3 enrolled as an agent under the requirements of Treasury Department Circular No. 230;

4 a bona fide officer of the taxpayer organization;

5 a full-time employee of the taxpayer;

6 a member of the taxpayer’s immediate family (spouse, parent, child or sibling);

7 a fiduciary for the taxpayer;

8 other (attach statement)

and that I am authorized to represent the taxpayer identified in Part 1 for the tax matters specified there.

Designation (insert appropriate

Jurisdiction (state, etc.)

number from above list)