Power Of Attorney Authorization - City Of Grand Rapids
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1CITY OF GRAND RAPIDS
INCOME TAX DEPARTMENT
POWER OF ATTORNEY AUTHORIZATION
Taxpayer Name
Phone Number
Account Number
1.
Address
City
State
ZIP Code
NOTE: Use item 7 to revoke an existing power of attorney.
From: (mo/day/yr)
To: (Expiration)*
This Power of Attorney Authorization is effective only for the inclusive dates:
/
/
/
/
2.
3.
Your authorized representative(s). This may be an organization, firm, partnership or individual. If your
representative is not an individual, you must designate a contact person. Submit additional forms if you have
more than two representatives. We will contact either representative unless you attach a letter specifying joint
contacts.
Representative Name
Telephone Number
Address
City
State
ZIP Code
Representative Name
Telephone Number
Address
City
State
ZIP Code
4.
General Authorization. My representative(s) is authorized to receive information and represent me as
indicated below (you must check a box for every item).
yes
no
q
q
a
To inspect or receive confidential tax information for all tax matters and years.
If no, complete item 5 below.
yes
no
q
q
b
To represent me and make oral or written presentations of fact or argument on my behalf
for all tax matters and years. If no, complete item 5 below.
yes
no
q
q
c
To sign returns and enter into agreements for me for all tax matters and years.
If no, complete item 5 below.
yes
no
q
q
d
Other authorization as specified here:
5.
Specific Authorization. Complete only if you check “no” to any statement in item 4.
Type of Grand Rapids Return
Tax Years or Tax Periods
a
b
c
d
6.
New Power of Attorney. This power of attorney revokes all earlier powers of attorney and tax information
authorization on file with the City of Grand Rapids Income Tax Department for the same tax matters and years
or periods covered by this power of attorney, except the following (specify person granted to, date and address
including ZIP code, or refer to attached copies of earlier powers and authorizations):
Initials
7.
No Power of Attorney. I revoke all powers of attorney previously submitted and
will represent myself in all tax matters. Initial here and complete item 8.
8.
Taxpayer’s
If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer,
Signature
I certify that I have the authority to execute this power of attorney.
Signature
Print or Type Name
Date
Signature
Print or Type Name
Date
*If this matter is not settled by the expiration date, you may have to file a new power of attorney.
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