Form 20a100 - Declaration Of Representative Page 2
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3FORM 20A100 (8-17)
DECLARATION OF REPRESENTATIVE
Page 2 of 3
5. CONSOLIDATED RETURN FILERS: If the taxpayer files a consolidated tax return per KRS 141.200(11), the
authorized acts will be extended to the subsidiaries included in the return. If any subsidiaries are to be excluded
from the authorized acts, list below.
FEDERAL IDENTIFICATION
NAME
TAX YEARS
NUMBER
6. RETENTION/REVOCATION OF PRIOR POWER(S) OF ATTORNEY OR REPRESENTATIVE AUTHORIZATION(S)
The filing of this authorization form automatically revokes any prior power(s) of attorney or representative authorization(s) on file
with the Department of Revenue for the same matter(s) and year(s) or period(s) covered by this document. If you do not want to
revoke any prior power(s) of attorney or representative authorization(s), you must attach a copy of any power(s) of attorney or
representative authorization(s) you wish to remain in effect for the same matter(s) and year(s) or period(s) covered.
7.
SIGNATURE OF TAXPAYER.
If a tax matter concerns a year in which a joint return was filed, each spouse must file a separate
representative authorization even if they are appointing the same representative(s). If signed by a corporate officer, partner,
guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf of the taxpayer, I certify that I have the legal
authority to execute this form on behalf of the taxpayer.
•
NOT VALID UNLESS COMPLETED, SIGNED, AND DATED BY THE TAXPAYER.
Signature
Date Signed
Print Name
Title (if applicable)
8. SIGNATURE OF REPRESENTATIVE
Under penalties of perjury, by my signature below I declare that:
•
I am not currently suspended or disbarred from practice, or ineligible for practice;
•
I am subject to regulations contained in Circular 230 (31 CFR, Subtitle A, Part 10) as amended, governing practice before the
Internal Revenue Service;
•
I am authorized to represent the taxpayer for the matter(s) specified; and
•
NOT VALID UNLESS COMPLETED, SIGNED, AND DATED BY THE REPRESENTATIVE(S).
Signature
Date Signed
Printed Name
PTIN (if applicable)
Signature
Date Signed
Printed Name
PTIN (if applicable)
Signature
Date Signed
Printed Name
PTIN (if applicable)
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