Power Of Attorney And Declaration Of Representative (Page 2 of 2) in pdf

Power Of Attorney And Declaration Of Representative Page 2

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Page2

If the power of attorney

is granted to a person other than an attorney

or certified public accountant,

the taxpayer(s)

signature

must be witnessed or

notarized

below. (The representative

must complete Part II. Only representatives

listed there are recognized

to practice before the Chicago

Department

of Revenue.)

The person(s) signing as or for the taxpayer(s):

(Check and complete one.)

[ I

is/are known to and signed in the presence of the two disinterested

witnesses whose signatures

appear here:

(Signature

of Witness)

(Signature

of Witness)

[ I

appeared

this day before a notary public and acknowledged

this power of attorney as a voluntary

act or deed.

(Date)

W itn ess: ....•....•........••••......•..•....•......•.•..•.....•....•....•..•....

(Signature

of Notary)

NOTARIAL SEAL

(Date)

(If required

by State Law)

PART II. - Declaration

of Representative

I declare that I am not currently

under suspension

or disbarment

from practice before any court or tribunal,

and that

I am one of the following:

1 a member in good standing of the bar of the highest court of the jurisdiction indicated below;

2 a bona fide officer of the taxpayer organization;

3 a full-time employee of tbe taxpayer;

4 a member oftbe ta.xpayer's immediate family (spouse,parent, child, brotber, or sister);

5 Director's special autborization

6 Certified Public Accountants.

and tbat I am autborized to represent the taxpayer identified in Part I for the tax matters there specified.

Designation

Jurisdiction

e number

(State, etc.) Signature

Date

Power Of Attorney And Declaration Of Representative Page 2

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