Reporting Firm Authorization Form

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REPORTING FIRM AUTHORIZATION FORM
Licensee’s 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 ___________________, 19 __________
_________________________________
Signature of Owner/Legal Representative
_________________________________
Title
ACKNOWLEDGEMENT
STATE OF _________________________ )
COUNTY OF ____________________________ )
On this _______ day of ______________, 19____, 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: ________________________
(Rev 10/97)

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