Form 33 - Power Of Attorney
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Power of Attorney
33
TAXPAYER’S NAME AND ADDRESS
Name of Taxpayer
Business Name
Address (Street or Other Mailing Address)
Business Address (Street or Other Mailing Address)
City
State
Zip Code
City
State
Zip Code
Nebraska ID or Social Security Number
Federal ID or Social Security Number
ATTORNEY-IN-FACT’S NAME AND ADDRESS
(If more than two, see Designation of Attorney-in-Fact in the instructions.)
Name
Name
Title or Firm Name
Title or Firm Name
Address (Street or Other Mailing Address)
Address (Street or Other Mailing Address)
City
State
Zip Code
City
State
Zip Code
Email Address
Phone Number
Email Address
Phone Number
The taxpayer appoints the above attorneys-in-fact for purposes of duly authorized representation in any proceedings with the Nebraska
Department of Revenue (Department) with respect to those tax categories, tax matters, and tax periods indicated below:
Tax Matter of Representation
Tax Category
Tax Period
The attorneys-in-fact designated on this form have the authority to receive confidential information on behalf of the taxpayer and the
power to perform the following acts with respect to the designated tax matters. Strike through any items which will not be granted.
•
Fully represent the taxpayer in any hearing, determination, or appeal.
•
Enter into any compromise with the Department.
•
Execute waivers, including offers of waivers, of restrictions on assessment or collection of tax deficiencies.
•
Execute waivers of notice of disallowance of a claim for credit or refund.
•
Execute consents extending the statutory period for issuing a notice of deficiency determination.
•
Receive, but not endorse or collect, checks in payment of any refund of taxes, penalties, or interest.
•
Receive all notices and other written communications with respect to the taxpayer in proceedings involving the above matters.
If more than one attorney-in-fact is named, enter name of the attorney-in-fact to receive these notices.
•
Perform other acts, specifically:
REVOCATION OF PRIOR POWERS OF ATTORNEY
A.
I choose to revoke all prior powers of attorney on file with the Department with respect to the same tax matters, and tax periods
listed above, except the following:
B.
I choose to revoke all powers of attorney on file with the Department.
If signed by a corporate officer, partner, member, LLC manager, or fiduciary on behalf of the taxpayer, I hereby certify that I have the authority to execute
this Power of Attorney on behalf of the taxpayer.
sign
Signature
Date
here
Title, If Applicable
Print Name
Email Address
Signature
Date
Title, If Applicable
Print Name
Email Address
7-139-1978 Rev. 7-2012 Supersedes 7-139-1978 Rev. 9-2009
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Parent category: Financial