Form Par 101 - Virginia Power Of Attorney And Declaration Of Representative Page 2
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24. Authorized Agent /Representative Information. Additional representatives should be listed on an
attached list and may not receive copies of correspondence.
Automatic Correspondence
Primary Representative – Must be a person; cannot be a business
An Authorized Agent will automatically be mailed
First Name*
Last Name*
copies of correspondence regarding the tax
matters.
Address
Authorized Agent Number
A - _________________________
Address
Do NOT mail copies of any correspondence
to agent.
City
State
ZIP Code
Mail copies of email communications to
agent.
Daytime Telephone Number
Fax Number
Email Address
(
)
(
)
Additional Representative – Must be a person; cannot be a business
Automatic Correspondence
An Authorized Agent will automatically be mailed
First Name
Last Name
copies of correspondence regarding the tax
matters.
Address
Authorized Agent Number
A - _________________________
Address
Do NOT mail copies of any correspondence
to agent.
City
State
ZIP Code
Mail copies of email communications to
agent.
Daytime Telephone Number
Fax Number
Email Address
(
)
(
)
5. Signature of Taxpayer(s) and Acknowledgment of Authorized Acts
By signing this form, I am granting the representative(s) listed in Section 4 the authority to:
•
Receive and inspect my confidential tax information for the tax matters listed in Section 3,
•
Perform all acts that I can perform with respect to the specified tax matters, and
•
Represent me before Virginia Tax, including consenting to extend the time to assess tax and executing consents that
agree to a tax adjustment.
•
In addition, I understand that the acts of my Authorized Agent may increase or decrease my tax liabilities and legal rights.
The authority does not, however, include the power to receive refund checks, substitute another representative, request a
copy of a tax return, sign certain returns, or consent to a disclosure of tax information.
For joint representation, both the taxpayer and the spouse listed in Section 1 must sign and date this form. If this form is
signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf of
the taxpayer, they certify that they have the authority to execute this form on behalf of the taxpayer. This power of attorney will
remain in effect until it is revoked by either the taxpayer or the agent.
Print Name*
Signature*
Title
Date*
Print Name
Signature
Title
Date
6. Representative Signature:
Under penalties of perjury, I declare I am authorized to represent the taxpayer(s)
listed in Section 1.
A.) Attorney
B.) Certified Public Accountant
C.) Enrolled Agent
D.) Family member or Other (provide relationship below):
____________________________________________________________________________________
Relationship:
Designation
Representative
Letter from
Print Name *
Representative Signature*
Date*
Above List
Primary
Additional
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