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STATE OF ARKANSAS

REVENUE DIVISION

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

REPORTING FIRM AUTHORIZATION FORM

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

_________________________________

Title

ACKNOWLEDGEMENT

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: ________________________

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