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Power Of Attorney Form

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Minnesota Department of Employment and Economic Development

Angel Tax Credit Program

POWER OF ATTORNEY FORM

Section I.

APPLICANT’S NAME AND IDENTIFYING INFORMATION

Applicant’s name (Business, Investor, or Fund name): ___________________________________________

Applicant’s Identification Number (SSN/TIN/FEIN): _____________________________________________

Spouse’s name (if married filing jointly): _____________________________________________________

Spouse’s Taxpayer Identification Number (SSN/TIN) (if married filing jointly): ________________________

Street Address: ________________________________________________________________________

City: ______________________________ State/Province: ____________ Country: _____ Zip: _________

Phone: ________________________________ Email: _________________________________________

Section II. APPOINTED POWER OF ATTORNEY

Check one:

Activate—This power of attorney is authorized to represent this appointee

Amend—changes an existing power of attorney for this appointee

Cancel/Revoke—cancels a previously filed power of attorney

I , the undersigned Applicant, appoint the following named Appointee to act as my attorney- in-fact to represent me before the

Minnesota Department of Employment and Economic Development for all matters related to the Minnesota Angel Tax Credit

Program. I understand that it is my responsibility to keep my appointee informed of my matters related to the program. I also

understand that the department does not send copies of all correspondence to my appointee.

Appointee name and contact information:

POA name:

Firm name (if applicable):

Street Address: ________________________________________________________________________

City: __________________________ State/Province: ___ Country: _____________ Zip: ____________

Phone: _____________________________ Email: _____________________________________________

Expiration date:

(If a date is not provided, this power of attorney is valid until revoked)

_____________________________________________________________________________________

Power of Attorney’s specimen signature

Date

MN DEED Angel Tax Credit Program

Power of Attorney Form 2016

Power Of Attorney Form

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