Form Nyc-Pa - Power Of Attorney Page 2
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Form NYC-PA
_______________________________________
________________________
Page 2
NAME
EIN
SSN
7 - ACKNOWLEDGMENT OR WITNESSING THE POWER OF ATTORNEY
This Power of Attorney must be acknowledged before a notary public or witnessed by one disinterested individual, unless the ap-
pointed representative is licensed to practice in New York State as an attorney-at-law, certified public accountant, or public accountant,
or is a New York State resident enrolled as an agent to practice before the Internal Revenue Service.
The person(s) signing as the above taxpayer appeared before me and executed this power of attorney.
Name of witness (print and sign)
Date
Mailing address of witness (please type or print)
ACKNOWLEDGMENT - INDIVIDUAL
ACKNOWLEDGMENT - CORPORATE
STATE OF
STATE OF
SS:
SS:
COUNTY OF
COUNTY OF
On this
day of
,
,
On this
day of
,
,
_____________________________
_____________________________________________
___________________
_____________________________
________________________________________________
___________________
before me personally came,
before me personally came,
to me known
______________________________________________________________________________,
________________________________________________________________,
to me known, who, being by me duly sworn, did say that he/she resides at
to be the person described in the foregoing Power of Attorney; and he/she acknowledged
that he/she executed the same.
______________________________________________________________________________________________________________________
INSERT ADDRESS
that he/she is the
of
______________________________________
____________________________________________________,
the corporation described in the foregoing Power of Attorney; and that he/she signed
his/her name thereto by authority of the board of directors of said corporation.
Signature of notary public
Date
Signature of notary public
Date
M
M
Notary public: L affix stamp L (or other indication of notaryʼs authority).
Notary public: L affix stamp L (or other indication of notaryʼs authority).
ACKNOWLEDGMENT - LIMITED LIABILITY COMPANY
ACKNOWLEDGMENT - PARTNERSHIP/LLP
STATE OF
STATE OF
SS:
SS:
COUNTY OF
COUNTY OF
On this
day of
,
,
On this
day of
,
,
____________________________
________________________________________________
_________________
_____________________________
_________________________________________________
__________________
before me personally came,
to me known,
before me personally came,
to me known,
_________________________________________________________,
____________________________________________________________,
who, being by me duly sworn, did say that he/she/they/it reside(s) at
who, being by me duly sworn, did say that he/she/they/it reside(s) at
_______________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
INSERT ADDRESS
INSERT ADDRESS
that he/she/they/it is (are) a partner(s) of
that he/she/they/it is (are) a member(s) or manager(s) of
______________________________________________________________
__________________________________________
the partnership described in the foregoing Power of Attorney; and that he/she/they/it is
the limited liability company described in the foregoing Power of Attorney; and that
(are) empowered to and did execute the same.
he/she/they/it is (are) empowered to and did execute the same.
Signature of notary public
Date
Signature of notary public
Date
M
M
Notary public: L affix stamp L (or other indication of notaryʼs authority).
Notary public: L affix stamp L (or other indication of notaryʼs authority).
8 - DECLARATION OF REPRESENTATIVE (to be completed by representative)
I agree to represent the above-named taxpayer in accordance with this power of attorney. I affirm that my representation will not violate the
provisions of section 2604 of the New York City Charter restricting appearances by current employees or former government employees. I
have read a summary of these restrictions reproduced in the instructions to this form.
I am (indicate all that apply):
4. a New York State resident enrolled as an agent to practice before the IRS
1. an attorney-at-law licensed to practice in New York State.
5. an employee, not a corporate officer (if the taxpayer is a corporation)
2. a certified public accountant duly qualified to practice in New York State
6. other.
3. a public accountant enrolled with the New York State Education Department
_______________________________________________________________________________
Designation
(use number(s)
Signature
Date
from above list)
NYC-PA
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