Form Mo 860-1723, Dor-2827 Draft - Sample Power Of Attorney - Missouri Department Of Revenue 2009 Page 2
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2SIGNATURE OF, OR FOR, TAXPAYER(S)
I (we) hereby certify that I (we) am (are) the taxpayer(s) named herein or that I have the authority to execute this power of
attorney on behalf of the taxpayer(s).
NAME
TITLE (IF APPLICABLE)
SIGNATURE
DATE
TAXPAYER TELEPHONE NUMBER
__ __ / __ __ / __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
NAME
TITLE (IF APPLICABLE)
SIGNATURE
DATE
TAXPAYER TELEPHONE NUMBER
__ __ / __ __ / __ __ __ __ (__ __ __) __ __ __ - __ __ __ __
DECLARATION OF REPRESENTATIVE
I declare that I am aware of Regulation 12 CSR 10-41.030 and that I am one of the following:
1. a member in good standing of the bar of the highest court of the jurisdiction indicated below;
2. a certified public accountant duly qualified to practice in the jurisdiction indicated below;
3. an officer of the taxpayer organization;
4. a full-time employee of the taxpayer;
5. a fiduciary for the taxpayer;
6. an enrolled agent; or
7. other
and that I am authorized to represent the taxpayer identified above for the tax matters there specified.
Note: All appointed representatives must sign below.
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
__ __ / __ __ / __ __ __ __
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
__ __ / __ __ / __ __ __ __
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
__ __ / __ __ / __ __ __ __
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
__ __ / __ __ / __ __ __ __
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
Please send completed forms to:
Missouri Department of Revenue
Missouri Department of Revenue
Taxation Division
Taxation Division
P.O. Box 357
P.O. Box 2200
Jefferson City, MO 65105-0357
Jefferson City, MO 65105-2200
Fax: (573) 522-1722
Fax: (573) 751-2195
(If reporting Business Tax)
(If reporting Personal Tax)
This publication is available upon request in alternative accessible format(s).
MO 860-1723 (11-2009)
DOR-2827 (11-2009)
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