Form Dr-835 - Power Of Attorney And Declaration Of Represntative

Re-print Taxpayer Name(s):

Taxpayer ID #

PAGE 2

Taxpayer(s) must complete Page 1 of this Power of Attorney, or it will be returned.

NOTICES AND COMMUNICATIONS

Notices and other written communications will be sent to the first representative listed in Part I, section 2, unless tax-

payer selects one of the options below.

If you want any notices and communications sent to both you and your representative, check this box ...............

If you do not want any notices or communications sent to your representative, check this box .............................

If you want the second representative listed to receive such notices and communications, check this box ..........

If you want the third representative listed to receive such notices and communications, check this box ...............

RETENTION / REVOCATION OF PRIOR POWER(S) OF ATTORNEY

The filing of this power of attorney automatically revokes all earlier power(s) of attorney on file with the Florida Department of

Revenue for the same tax matters and years or periods covered by this document. If you do not want to revoke a prior power of

attorney, check this box ..........................................................................................................................................

YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.

SIGNATURE OF TAXPAYER(S)

If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested. If signed by a corporate

officer, partner, member/managing member, guardian, tax matters partner/person, executor, receiver, administrator, trustee, or fiduciary

on behalf of the taxpayer, I declare under penalties of perjury that I have the authority to execute this form on behalf of the taxpayer.

Under penalties of perjury, I (we) declare that I (we) have read the foregoing document, and the facts stated in it are true.

If this Power of Attorney is not signed and dated, it will be returned.

___________________________________________________

_______________________

SIGNATURE

DATE

TITLE (If Applicable)

___________________________________________________

PRINT NAME

___________________________________________________

_______________________

SIGNATURE

DATE

TITLE (If Applicable)

___________________________________________________

PRINT NAME

PART II - DECLARATION OF REPRESENTATIVE

Under penalties of perjury, I declare that:

I am not currently under suspension or disbarment from practice before the Internal Revenue Service;

I am aware of regulations contained in Treasury Department Circular No. 230 (31 CFR, Part 10), as amended, concerning the

practice of attorneys, certified public accountants, enrolled agents, enrolled actuaries, and others;

I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified therein, and to receive

confidential taxpayer information;

I am one of the following:

Attorney - a member in good standing of the bar of the highest court of the jurisdiction shown below.

Certified Public Accountant - duly qualified to practice as a certified public accountant in the jurisdiction shown below.

Enrolled Agent / Actuary - enrolled as an agent or actuary under the requirements of Treasury Department Circular No.

230. (Attach evidence of enrolled status.)

Law student who is certified pursuant to Chapter 11 of the Rules Regulating the Florida Bar.

Former Department of Revenue employee. As a tax representative, I cannot accept representation in a matter upon the

merits of which I had direct involvement while I was a public employee.

Other Qualified representative. (Note: Representatives qualifying under this subsection must comply with Rules 12-6.005

and 28-106.106, Florida Administrative Code.);

I have read the foregoing Declaration of Representative and the facts stated in it are true.

If this Declaration of Representative is not signed and dated, it will be returned.

DESIGNATION - INSERT

JURISDICTION (State) or

SIGNATURE

DATE

ABOVE LETTER (a - f)

ENROLLMENT CARD NO.

Form Dr-835 - Power Of Attorney And Declaration Of Represntative - 2004 Page 2

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