Form Gen-58b - Power Of Attorney For Bankruptcy Matters - Department Of Revenue - North Carolina

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4
North Carolina Department of Revenue
GEN-58B
POWER OF ATTORNEY
4-06
PRINT
CLEAR
For BANKRUPTCY MATTERS
I,
do hereby make, constitute and appoint,
(Taxpayer(s) Name)
my true and lawful attorney in fact to represent and obtain tax information from the
(Attorney Name)
North Carolina Department of Revenue, in connection with debt counseling and any pending, prospective, or potential bankruptcy filings.
TAXPAYER Signature (Single Filer)
TAXPAYER Signature (Joint Filer/Spouse)
Taxpayer ID Number
Taxpayer ID Number
Date
Date
** If joint bankruptcy is filed, signatures of both husband and wife are required**
INFORMATION REQUESTED (Please check all that apply)
Acknowledgement of tax return(s) filed - (specify tax schedule & year)
Tax Schedule(s)
Tax years/periods
OR
Copy of tax return(s) - (specify tax schedule & year)
Tax Schedule(s)
Tax years/periods
Liability Currently Due
Other (Specify)
Taxpayer Information:
Taxpayer(s) Name:
Address:
Taxpayer ID Number:
Account Number if business:
Attorney Contact Information:
Contact Name:
Mailing Address:
Telephone Number:
Fax Number:
Mail or Fax Request To: NC Department of Revenue
Fax: (919) 715-0068
Attn: Bankruptcy Unit
PO Box 1168
Raleigh, NC 27602-1168

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