Reporting Firm Authorization Form - Department Of Finance And Administration - State Of Arkansas


Motor Fuel Tax Section
Department of Finance
Post Office Box 1752
Little Rock, Arkansas 72203-1752
and Administration
Phone: (501) 682-4800
Fax: (501) 682-5599
Licensees are required to file applications/returns and pay taxes as owed. They are also required to accept and respond to
various types of official communications with the Department of Revenue.
If a licensee prefers a Reporting Service to fulfill these responsibilities, this form is to be completed. This is a privilege
extended to the licensee which requires special handling by the Department, therefore, such action will not be considered
unless this form is properly completed and placed on file with the Department. The completion of this form does not
relieve the licensee of the legal obligations associated with a particular license. The licensee is ultimately responsible for
the payment of taxes as well as all acts and omissions of the stated Reporting Service.
Power of Attorney
KNOW ALL MEN BY THESE PRESENT, that the undersigned principal and licensee has made and appointed, and
does hereby make and appoint (Firms Name)
(Mailing Address)
(Phone Number),
to act as Attorney-in-Fact for the licensee, who makes this appointment either personally or in an authorized
representative capacity on behalf of the including licensing ; this power of attorney shall be for all matters related to
IFTA fuel taxes including licensing, decal orders, fuel tax reports and discussing all required documents with any agent
of the commissioner of Revenue.
IN WITNESS WHEREOF, I, ________________________________________________
have set my hand this _______________ day of ___________________, 20 __________
Signature of Owner/Legal Representative
STATE OF _________________________ )
COUNTY OF ____________________________ )
On this _______ day of ______________, 20____, before me, the undersigned Notary Public, in and for the
county and state aforesaid personally appeared ______________________________________
and acknowledged to me that he executed the same as his free and voluntary act and deed, of said corporation, for the
uses and purposes therein set forth.
Given under my hand and seal the day and year last above written.
Notary Public _________________________________
My commission Expires: ________________________


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