Department of Revenue Services
State of Connecticut
25 Sigourney Street
Power of Attorney
Hartford CT 06106-5032
Part I: Taxpayer(s) Giving a Power of Attorney to Another Person
Social Security Number
Spouse’s Name (Personal income tax or individual use tax only)
Social Security Number
Connecticut Tax Registration Number
Federal Employer Identiﬁ cation Number
Taxpayer is: (Check box)
Trust (other than a business trust)
Limited Liability Company
Other (specify) ____________________________________
Part II: Declaration of Person(s) Giving Power of Attorney and Powers Given
See instructions for who may execute this power of attorney. This power of attorney revokes all previous powers of attorney on ﬁ le with
the Department of Revenue Services (DRS) for the same tax matters and years or periods covered by this power of attorney.
Any of the attorney(s)-in-fact are authorized, subject to revocation, to receive tax returns and tax return information as deﬁ ned in Conn.
Gen. Stat. §12-15, and to perform on behalf of the taxpayer(s) the following acts for the tax matters described below. The authority does
not include the power to sign certain returns unless speciﬁ cally stated below.
Check the boxes for the powers given to:
Receive, but not to endorse and collect, checks (made payable to the taxpayer mentioned above) in payment of any refund of
Connecticut taxes, penalties, or interest.
Execute waivers (including offers of waivers) of restrictions on assessment or collection of deﬁ ciencies in tax and waivers of notice
of disallowance of a claim for credit or refund.
Execute or terminate consents extending the statutory period for assessment or collection of tax.
Execute closing agreements under Conn. Gen. Stat. §12-2e.
Delegate authority or to substitute another representative.
Represent the taxpayer(s) named above before DRS.
Sign returns. (See instructions.)
Declaration: I am the taxpayer identiﬁ ed in Part I, or if I am not the taxpayer identiﬁ ed in Part I, I have been authorized by the taxpayer to execute
this power of attorney on behalf of the taxpayer and I am permitted by the instructions on this Form LGL-001 to execute this power of attorney.
I declare under penalty of law that I have examined this document (including any accompanying schedules and statements) and, to the best of
my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a
ﬁ ne of not more than $5,000, or imprisonment for not more than ﬁ ve years, or both.
Print Name: ____________________________________________________________
Part III: Power of Attorney Given To
The taxpayer(s) named above appoints the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before DRS and receive
tax returns and return information for the following tax matters. Specify all tax types and periods affected by this power of attorney with the
understanding that this authority applies only to the tax types and periods listed below. Enter the date of death for succession and estate taxes.
Indicate the representative to whom a copy of any notice from DRS should be sent by checking the box below. Check one box only.
Check One Box
Tax Type (Sales Tax, Gift Tax, etc.)
Year(s) or Period(s)