Form M-5041 - Power Of Attorney printable pdf download

M-5041

(11-09)

State of New Jersey

DEPARTMENT OF THE TREASURY

UNCLAIMED PROPERTY ADMINISTRATION

50 BARRACK STREET

PO BOX 214

TRENTON, NJ 08695-0214

POWER OF ATTORNEY

, __________________________________, _____________________________________

(Print Name)

(Identification Number)

_______________________________________________________________________

hereby appoint

(Print Name)

(Print Address)

(Telephone Number)

as attorney-in-fact to represent us before any office and/or representative of the State of New Jersey, Department of the

Treasury, Unclaimed Property Administration, with respect to any audit functions and/or proceedings for the year(s) or

period(s):

__________________________________________________________________________________

(Please Print)

Said attorney-in-fact shall, subject to revocation in writing, have authority to receive confidential information and full

power to perform on behalf of the holder(s): All acts necessary and requisite to facilitate said audit functions and/or

proceedings; to executive consents extending the statutory period for reporting or remittance of unclaimed property, to

delegate authority or to substitute another representative of the same firm or company.

______________________________________________________________

Other acts (specify)

__________________________________________________________________________________

(Please Print)

Copies of notices and other written communications addressed to the holder(s) in proceedings involving the above matters

should be sent to:

___________________________________________________________________________________________________

(Please Print)

This power of attorney revokes all prior powers of attorney and unclaimed property authorizations on file with the same

Unclaimed Property Administration with respect to the same matters and years or periods covered by this instrument.

___________________________________________________________________________________________________

(Signature of or for holder(s))

(Date)

If signed by a corporate officer, partner, or fiduciary on behalf of the holder, I certify that I have the authority to execute

this power of attorney on behalf of the holder.

___________________________________________________________________________________________________

(Signature)

(Title, if applicable)

(Date)

___________________________________________________________________________________________________

(Signature)

(Title, if applicable)

(Date)

Form M-5041 - Power Of Attorney

Related Articles

Related forms

Related Categories