Form Tc-191 - Declaration Of Representative To Take Possession Of Cigarette Stamps
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Utah State Tax Commission
TC-191
Declaration of Representative
Rev. 8/13
To Take Possession of Cigarette Stamps
Utah State Tax Commission, Taxpayer Servcies Division, 210 N 1950 W, Salt Lake City, UT 84134-7000, 801-297-2200, Fax 801-279-7699
Licensed taxpayers use this form to appoint authorized representatives to take possession of cigarette stamps and revoke
authorization to take possession of cigarette stamps.
Licensed taxpayer name
FEIN
TOB account number
Address
Representatives named below are authorized to take possession of cigarette stamps on behalf of the licensed taxpayer above
Name
Telephone number
Fax number
Name
Telephone number
Fax number
Name
Telephone number
Fax number
Authorization for Individual(s) named below to take possession of cigarette stamps are revoked
Name
Telephone number
Fax number
Name
Telephone number
Fax number
Name
Telephone number
Fax number
Licensed taxpayer’s signature to authorize or revoke representatives to take possession of cigarette stamps
As the licensed taxpayer (authorized principal officer, partner, member, agent or attorney-in-fact), I authorize individual representatives
listed above to take possession or revoke the individual representatives listed above to take possession of cigarette stamps on behalf
of the licensed taxpayer. I further certify that I am the licensed taxpayer.
Signature of taxpayer (or designee)
Title
Date
Distribute this form to Taxpayer Services Division at the front counter.
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