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Form 2848-Me - Power Of Attorney And Declaration Of Representative - Maine Revenue Services Page 2

Page 2

If the power of attorney is granted to a person other than an attorney, certified public accountant or

enrolled agent, the taxpayer(s) signature must be witness or notarized below. (The representative must

complete Part II.)

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.

Witness:

NOTARIAL SEAL

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _

(Signature of Notary)

(Date)

PART II Declaration of Representative

I declare 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 in the jurisdiction shown below;

3. A bona fide officer of the taxpayer organization;

4. A full-time employee of the taxpayer;

5. A member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);

6. A fiduciary for the taxpayer;

7. Other (Explain)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Designation

Jurisdiction

Signature

Date

(insert appropriate

(state, etc.)

number from above list)

Form 2848-Me - Power Of Attorney And Declaration Of Representative - Maine Revenue Services Page 2