Form Poa-1 - Indiana Department Of Revenue Power Of Attorney
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1INDIANA DEPARTMENT OF REVENUE
POA -1
POWER OF ATTORNEY
Revised 4/90
TIPS FORM
Taxpayer(s) Name(s)
Taxpayer Identification #
Address
RRMC#
City
Federal ID#
_
State
Zip
SSN #
_
_
Hereby appoint(s) the following:
(If Firm or Corp, give Appointee(s) Name)
Firm/Corp/Individual Name
Address
Appointee
Phone
Year(s)/Period(s)
Type of Tax
Said attorney(s) - in - fact shall (subject to revocation) have authority to receive confidential information and full power to perform on
behalf of the undersigned all acts incidental to such representation:
If signed by the Corporate Officer, Partners, or Fiduciary on behalf of the taxpayer, I certify that I have authority to execute this Power
of Attorney on behalf of the taxpayer:
Signature
Date
Title
Subscribed and sworn to before me this
day of
.
My Commission Expires
Notary Public
County
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Parent category: Financial