Form R-7005 - Power Of Attorney

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R-7005 (9/05)
Power of Attorney
Short Form
(Please Type or Print.)
State of ______________________________________
Parish/County of ______________________________________
Your Name or Name of Entity
Social Security Number/Louisiana or Federal ID Number
____________________________________________
____________________________________________________
Spouse name, if joint (or corporate officer,
partner or fiduciary, if a business)
Spouse Social Security Number (if a joint return)
____________________________________________
____________________________________________________
________________________________________
Mark one:
❒ ❒ Original – your first power of attorney authorizing this
Street Address
agent and attorney-in-fact
________________________________________
❒ ❒ Amend – changes an existing power of attorney for
City/State/ZIP
(name) __________________________________________
Expiration Date __________________________
❒ ❒ Cancel/Revoke – cancels a previously filed power of
Month/Day/Year
attorney for (name) ____________________________
I/We hereby make, name, constitute and appoint
________________________________________________________
Agent and attorney-in-fact
____________________________________________________
__________________________________________________
Mailing Address
Telephone and Fax Numbers
____________________________________________________
__________________________________________________
City/State/ZIP
E-mail address
my/our true and lawful agent and attorney-in-fact for me/us and in my/our name, place, and stead to receive and inspect
confidential tax information and to perform any and all acts, including signing a tax return, that this taxpayer can perform
with respect to the taxes and taxable year(s) or period(s) set forth below. The authorizations granted above apply to
_______________________________________________________________
Louisiana______
tax(es)
List tax types
___________________________________________________________ .
for the taxable year(s) or period(s)
The agent and attorney-in-fact shall be authorized to receive copies of notices and communications from the Louisiana
Department of Revenue upon request. The taxpayer will receive the original notices and written communications. The
authority does not include the power to receive and to sign refund checks or the power to substitute another
representative unless specifically added below.
List any specific additions or deletions to the acts otherwise authorized in this power of attorney.

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