Form Rd-1061 - Power Of Attorney And Declaration Of Representative - Georgia Department Of Revenue Page 2
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Form RD-1061
Page 2
(Rev. 09/29/16)
Section 5
Taxpayer(s) Authorization and Signature(s)
► The taxpayer(s) named in Section 1 appoints the individual(s) named in Section 2 as attorney(s)-in-fact for the taxpayer(s)
concerning the tax matters listed in Section 3.
► The taxpayer(s) acknowledge that it is their responsibility to keep the representative(s) listed in Section 2 informed of the tax matters
involving the Department and that the Department is not able to send copies of correspondence to the representative(s).
This power of attorney is not valid until it is signed and dated. If signed by a corporate officer, partner, guardian, executor, receiver,
administrator, fiduciary, or trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the
taxpayer. I understand that to willfully prepare or present a document that is fraudulent or false is a crime under O.C.G.A. § 48-1-6.
Signature
Print name
Date
Title (if officer, etc.)
Spouse’s signature (if joint)
Print spouse’s name
Date
Section 6
Witnessing or Acknowledgment of the Power of Attorney
This power of attorney must be either witnessed by two disinterested individuals OR acknowledged by the taxpayer(s) before a notary
public, unless the appointed representative(s) is licensed to practice as an attorney-at-law, certified public accountant, a registered
public accountant, or is enrolled as an agent to practice before the Internal Revenue Service (see Section 7 below).
Witnessing of power of attorney. The person(s) signing as the taxpayer(s) in Section 5 above appeared before us and
executed this power of attorney.
Signature of Witness
Signature of Witness
Name of Witness (type or print)
Name of Witness (type or print)
Mailing Address of Witness (type or print)
Mailing Address of Witness (type or print)
City
State
ZIP Code
City
State
ZIP Code
Acknowledgement of power of attorney. The person(s) signing as the taxpayer(s) in Section 5 above appeared this
day before a notary public and acknowledged this power of attorney as a voluntary act and deed.
NOTARY SEAL
(Signature of Notary)
Date
Section 7
Declaration of Representative
Under penalties of perjury, I declare that:
• I am authorized to represent the taxpayer identified in Section 1 for the matter(s) specified in Section 3 of this form; and
• I am one of the following (indicate all that apply):
1.
An attorney-at-law licensed to practice in and a member in good standing of the Bar of the jurisdiction indicated below.
2.
A certified public accountant duly qualified to practice in the jurisdiction indicated below.
3.
Enrolled as an agent to practice before the Internal Revenue Service under the requirements of Circular 230.
4.
A registered public accountant.
Designation –
Bar, license, certification,
use number(s)
Licensing jurisdiction (state) or other
registration, or enrollment number
Signature
Date
from above list
licensing authority (if applicable)
(1 - 4)
Please note that the representatives listed in this section may alternatively use Federal Form 2848,
provided the matters section lists Georgia information.
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