Power Of Attorney And Declaration Of Representative - Oregon Department Of Revenue - 2003
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1POWER OF ATTORNEY AND
FOR OFFICE USE ONLY
O R E G O N
Date Received
DECLARATION OF REPRESENTATIVE
D E PA R T M E N T
O F R E V E N U E
(Please print)
Taxpayer Name(s)
Social Security Number or Other Identifying Number
Address
City
State
ZIP Code
Check the tax program(s) this declaration applies to:
Personal Income Tax
Partnership/LLP
Payroll/Withholding Tax
Timber Tax
Elderly Rental Assistance
Limited Liability Co.—filed as:
Tri-Met Transit Tax
Other Agency Accounts
Corporation Tax
Partnership
Lane Transit District Tax
Other: _______________
____________________
Fiduciary Income Tax
Corporation
Property Tax
I hereby appoint the following person as attorney-in-fact for tax year(s) ______________________________________________:
Name
Title and License Number
Telephone Number
Fax Number
(
)
(
)
Mailing Address
City
State
ZIP Code
Check all that apply:
OPTION A—Power of Attorney to Receive Confidential Information: To inspect, provide to, and/or receive from the Oregon
Department of Revenue, information relating to the taxpayer(s)’ liability for tax(es), interest, penalty, or other charges for the tax
year(s) and tax program(s) indicated above. Information does not include service of original notices of deficiency, assessment, or
refund adjustments.
OPTION B—Power of Attorney to Represent and Receive Confidential Information: (See qualification requirements on the
back). To represent the taxpayer(s) before the Oregon Department of Revenue in any manner relating to the taxpayer(s)’ liability for
tax(es), interest, penalty, or other charges for the tax year(s) indicated above. This representative has full power to do all things
necessary as fully and with as binding effect as the taxpayer(s) might do, including, but not limited to, providing information; preparing,
signing, executing, and filing reports and returns; inspecting reports or returns on file; executing extensions of statutes of limitations;
and executing closing agreements. Individuals appointed to represent taxpayers must meet the qualifications of ORS 305.230.
List any specific additions or deletions to the acts otherwise authorized in Option A or B above: __________________________
___________________________________________________________________________________________________________
To designate a tax matters partner or shareholder [see OAR 150-305.230(1) and (2) and 150-305.242(2) and (5)].
Partnership or S corporation name: ____________________________________________________________________________
All power(s) of attorney for this purpose that were previously filed or executed for the tax years referenced are still valid.
SIGNATURE OF TAXPAYER(S)
If a tax matter concerns a joint return, both spouses must sign if joint representation is requested. If signed by a corporate officer,
partner, fiduciary, or other qualified person signing on behalf of the taxpayer(s), I certify that I have the authority to execute this form on
behalf of the taxpayer(s).
Signature
Print Name
Date
X
Telephone Number
Title (if applicable)
(
)
Signature
Print Name
Date
X
Title (if applicable)
Telephone Number
(
)
Please complete the following, if known (for routing purposes only):
Send to: Oregon Department of Revenue
Revenue Employee: _____________________________________
955 Center St NE
Division/Section: ________________________________________
Salem OR 97301-2555
Employee Telephone Number: _____________________________
Employee Fax Number: ___________________________________
Qualifications for representation are on the back
150-800-005 (Rev. 1-03) Web
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