Form 2848 Draft - Power Of Attorney And Declaration Of Representative - 2011 Page 2

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Version A, Cycle 2

Form 2848 (Rev. 10-2011)

Page

Retention/revocation of prior power(s) of attorney. The filing of this power of attorney automatically revokes all earlier power(s) of

attorney on file with the Internal Revenue Service for the same matters and years or periods covered by this document. If you do not want

to revoke a prior power of attorney, check here .

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YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.

Signature of taxpayer. If a tax matter concerns a year in which a joint return was filed, the husband and wife must each file a separate power

of attorney even if the same representative(s) is (are) being appointed. 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 authority to execute this form on behalf of the

taxpayer.

IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED TO THE TAXPAYER.

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Signature

Date

Title (if applicable)

Print Name

PIN Number

Print name of taxpayer from line 1 if other than individual

Part II

Declaration of Representative

Under penalties of perjury, I declare that:

• I am not currently under suspension or disbarment from practice before the Internal Revenue Service;

• I am aware of regulations contained in Circular 230 (31 CFR, Part 10), as amended, concerning practice before the Internal Revenue Service;

DRAFT AS OF

• 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—a member in good standing of the bar of the highest court of the jurisdiction shown below.

b Certified Public Accountant—duly qualified to practice as a certified public accountant in the jurisdiction shown below.

October 17, 2011

c Enrolled Agent—enrolled as an agent under the requirements of Circular 230.

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, grandchild, step-parent, step-

child, brother, or sister).

g Enrolled Actuary—enrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the authority to practice before

the Internal Revenue Service is limited by section 10.3(d) of Circular 230).

h Unenrolled Return Preparer - Your authority to practice before the Internal Revenue Service is limited. You must have been eligible to sign the

return under examination and have signed the return. See Notice 2011-6 and Special rules for registered tax return preparers and unenrolled

return preparers in the instructions.

i Registered Tax Return Preparer—registered as a tax return preparer under the requirements of section 10.4 of Circular 230. Your authority to

practice before the Internal Revenue Service is limited. You must have been eligible to sign the return under examination and have signed the

return. See Notice 2011-6 and Special rules for registered tax return preparers and unenrolled return preparers in the instructions.

k Student Attorney or CPA—receives permission to practice before the IRS by virtue of his/her status as a law, business, or accounting student

working in LITC or STCP under section 10.7(d) of Circular 230. See instructions for Part II for additional information and requirements.

r Enrolled Retirement Plan Agent—enrolled as a retirement plan agent under the requirements of Circular 230 (the authority to practice before the

Internal Revenue Service is limited by section 10.3(e)).

IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE

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RETURNED. REPRESENTATIVES MUST SIGN IN THE ORDER LISTED IN LINE 2 ABOVE. See the instructions for Part II.

Note: For designations d-f, enter your title, position, or relationship to the taxpayer in the "Licensing jurisdiction" column. See the instructions for Part

II for more information.

Licensing jurisdiction

License/Bar or

Designation—Insert

(state) or other

Enrollment Number

Signature

Date

above letter (a–r)

licensing authority

(if applicable)

2848