Form 21-002 - Power Of Attorney And Declaration Of Representation

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POWER OF ATTORNEY
and
DECLARATION of REPRESENTATION
Form 21-002-11
PART I POWER OF ATTORNEY
For DOR Use Only
Taxpayer(s) Information
Taxpayer Name(s) and Mailing Address
Taxpayer Social Security Number
Received by:
Name __________________________
Spouse Social Security Number
Phone __________________________
Federal ID Number (FEIN)
____________________
Date
Hereby appoint(s) the following representative(s):
Representative Information
Name and Mailing Address
882-5338
877
(
)
Gregory Nordt c/o Amerihope Alliance Legal Services
Phone Number
_________________________________________________
7501 NW 4th Street, 207A
615-1077
954
(
)
Plantation, FL 33317
FAX Number
_________________________________________________
Name and Mailing Address
(
)
Phone Number
________________________________________________
(
)
FAX Number
_________________________________________________
Name and Mailing Address
(
)
Phone Number
_________________________________________________
(
)
FAX Number
_________________________________________________
To represent the taxpayer(s) before the Mississippi Department of Revenue in:
Tax Matter(s)
Tax Type (Income, Franchise, Sales, Insurance Premium, etc.)
Account Number
Tax Period(s)
Acts Authorized
I (we) as the taxpayer(s) give authorization to the representative(s) to receive and inspect confidential tax information and
to perform any and all acts that the taxpayer(s) can perform with respect to the matters concerning the taxes and accounts
described under Tax Matter(s) above, for example, the authority to sign any agreements, consents or other documents
and to represent the taxpayer(s) in any informal or formal proceeding involving the Department of Revenue. The authority
of the representative(s) does not and cannot include the power to substitute another representative or to request that tax
return(s) or other confidential tax information of the taxpayer(s) be inspected by or disclosed to another person. The
authority also does not include the authority to receive tax refund checks or to sign returns unless specifically added below.
List any specific additions or deletions to the acts otherwise authorized by this Power of Attorney:
Additions: ____________________________________________________________________________________
Deletions: ____________________________________________________________________________________
The Department of Revenue
may reject a submission due to incompleteness, lack of specificity, or inappropriateness.
Retention/Revocation of Prior Power(s) of Attorney
The filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Department of Revenue
for the same tax matter(s) covered by this document. If you do not want to revoke a prior Power or Attorney,
check here
and ATTACH A COPY OF THE POWER(S) OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.
DEPARTMENT OF REVENUE
P.O. BOX 1033
JACKSON, MS 39215-1033
Phone: 601-923-7000

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