Form Poa-1 - Power Of Attorney - Indiana Department Of Revenue Page 2

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If firm or vendor, list representative(s) name, telephone number and email.

Representative(s) Name

Telephone Number

5. General Authorization

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I authorize the listed representative(s), in addition to anything otherwise authorized on this form, to represent me regarding any

matters with the Indiana Department of Revenue regardless of tax years or income periods. I understand that this authority will expire 5

years from the date this POA is signed or a written and signed notice is filed revoking this authorization.

6. Tax Type(s) (Not applicable if box is checked in question 5 above)

Type of Tax

Year(s)/Period(s)

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(Income, Withholding, Sales, etc.)

Current Year

Specify

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I acknowledge that the designated representative has the authority to receive confidential information and full power to perform on behalf of

the taxpayer in tax matters related to this Power of Attorney. This authority does not include the power to receive refund checks.

I acknowledge that actions taken by the designated representative are binding, even if the representative is not an attorney. Proceedings

cannot later be declared legally defective because the representative was not an attorney.

If I am a corporate officer, partner, or fiduciary acting on behalf of the taxpayer, I certify that I have authority to execute this Power of Attorney

on behalf of the taxpayer.

7. Authorizing Signature

Signature _______________________________________________

Date _______________________________

Printed Name ____________________________________________

Title _______________________________

Telephone Number ________________________________________

Email ______________________________

Required fields - if not complete, this form will be returned to sender.