Form Poa - Power Of Attorney - Authorization To Disclose Information - Montana Department Of Revenue Page 2
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24.
Acts Authorized by This Form
Check the box that best describes what authorization you are delegating to your representative.
Representation. Department employees can provide confidential information to the representative and discuss the information.
q
Information sharing. Department employees can provide confidential information to the representative, but cannot discuss
q
the information.
Decision-making authority. Department employees can provide confidential information to a representative, can discuss
q
the information and the representative can act on the taxpayer’s behalf for all purposes, including settlement and waiver of
appeal rights.
5.
Revocation of Prior Power(s) of Attorney
Check this box if you want all prior POAs revoked.
q
If you are a representative and want to withdraw an existing POA, write WITHDRAW across the top of the existing form. See
instructions on page 3.
6.
Signature of taxpayer. If a tax matter concerns a year in which a joint return was filed, the spouses each file a separate power of
attorney even if the same representative(s) is(are) appointed. If signed by a corporate officer, partner, guardian, tax matters partner,
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.
If not signed and dated, this power of attorney will not be in effect and the taxpayer will be notified.
_______________________________________
____________________
__________________________________
Signature
Date
Title (if applicable)
_______________________________________
__________________________________
Print Name
Print name of Taxpayer from Line 1 (if other
than individual)
PART II. Declaration of Representative
I declare that:
I am authorized to represent the taxpayer identified in Part I for the matter(s) specified there; and
I am one of the following:
a. Attorney - licensed to practice law in the jurisdiction shown below.
b. Certified Public Accountant - duly qualified to practice as a certified public accountant in the jurisdiction shown below.
c. Enrolled Agent or Licensed Public Accountant, etc.
d. Officer - a bona fide officer of the taxpayer’s organization.
e. Full time employee - a full time employee of the taxpayer.
f. Family member - a member of the taxpayer’s immediate family (for example, spouse, parent, child, grandparent, step-parent,
step-child, brother, or sister).
g. Other
Representative Signature. See instructions on page 4.
Designation -
Relationship to Taxpayer
Insert Letter from
Signature
Date
(see instructions for Part II)
Above (a-g)
Filing this Form
► File Online on Taxpayer Access Point at https://tap.dor.mt.gov.
Under the Business Section, select Add Power of Attorney
► Fax to: (406) 444-7723.
Or, if you are already working with a department employee, fax your completed form to the number
provided by that person.
► Mail the completed form to:
Montana Department of Revenue
340 N. Last Chance Gulch
PO Box 5805
Helena, MT 59604-5805
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