Form 21-002 - Power Of Attorney And Declaration Of Representation Page 2
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2DOR Power of Attorney, Form 21-002
Signature of Taxpayer(s)
If a tax matter(s) concerns a joint return, both husband and wife must sign if joint representation is requested. If signed by a
corporate officer, partner, guardian, conservator, executor, receiver, administrator, conservator or trustee on behalf of the
taxpayer(s), I certify that I have the authority to execute this form on behalf of the taxpayer(s). A corporation or subsidiary MUST
contain the signatures of a principal officer and the secretary or other officer. A guardian, executor, receiver, administrator,
conservator or trustee MUST attach the appropriate documentation granting the authority from the courts or taxpayer(s).
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
Signature
Date
Title (if applicable)
Print Name
Phone Number
FAX Number
Signature
Date
Title (if applicable)
Print Name
Phone Number
FAX Number
ACKNOWLEDGMENT
State of _____________________________
County of ____________________________
Personally appeared before me, the undersigned authority in and for the said county and state, on this ________ day
DATE
of __________________, 20______, within my jurisdiction, the within named ______________________________,
MONTH
YEAR
TAXPAYER(S)
who acknowledged to me that __________ executed the above and foregoing instrument as _______________________
HE / SHE / THEY
TAXPAYER(S) OR TITLE
on behalf of the taxpayer(s) identified in Taxpayer(s) Information of PART I of this instrument, after having been duly
authorized by said taxpayer(s) so to do.
My Commission Expires:
(SEAL)
____________________________________________________
Notary Public
PART II DECLARATION OF REPRESENTATIVE
Under penalties of perjury and Miss. Code Ann. §97-7-10, I declare that:
1)
I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there: and
2) I am one of the following:
a. Attorney – a member in good standing of the bar of the highest court of the jurisdiction shown below.
b. Certified Public Accountant – duly authorized to practice as a certified public accountant in the jurisdiction shown.
c. Officer – a bona fide officer of the taxpayer’s organization.
d. Full-time employee – a full time employee of the taxpayer.
e. Family Member – a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister.
f. Enrolled Agent – enrolled as an agent under the requirements of the IRS.
g. Other – Provide explanation ________________________________________________________________
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
Designation – Insert
State Issuing
State License
Signature
Date
Above letter (a-g)
License
Number
DEPARTMENT OF REVENUE
P.O. BOX 1033
JACKSON, MS 39215-1033
Phone: 601-923-7000
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