Form Poa-1 - Power Of Attorney - Indiana Department Of Revenue

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POA - 1
Indiana Department of Revenue
State Form 49357
POWER OF ATTORNEY
(R4 / 4-13)
1. Taxpayer Information
Taxpayer(s) Name(s)
DBA Name(s) (if applicable)
Address
New Address?
City
State
Zip Code
Telephone Number
2. Identification Numbers
Indiana Taxpayer Identification Number (10 digits)
or
Employer Identification Number
Social Security Number
Spouse’s Social Security Number
Hereby appoint(s) the following:
3. Representative Information
Additional Individual Representative Name
Individual Representative Name
Address
Address
City
State
Zip Code
City
State
Zip Code
Telephone Number
Email
Telephone Number
Email
Additional Individual Representative Name
Additional Individual Representative Name
Address
Address
City
State
Zip Code
City
State
Zip Code
Telephone Number
Email
Telephone Number
Email
4. Firm/Vendor Information
Firm/Vendor Name (if applicable)
Address
City
State
Zip Code
Telephone Number
Email

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