Form Ftb 3520 - Power Of Attorney Declaration Page 2
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5Part 4 – Tax Years or Income Periods Covered by the POA
The representative(s) listed can represent you before us for the following tax years or income periods listed below.
4A
– Calendar Year (e.g., 2010 or 2010 - 2012)
4B
– Fiscal and Short-Period Income Years (to list additional income years attach a list including all required information to this form)
Year Begins on:
Year Ends on:
Year Begins on:
Year Ends on:
MM/DD/YEAR
MM/DD/YEAR
MM/DD/YEAR
MM/DD/YEAR
Required
Required
Required
Required
(e.g., 07/01/2010)
(e.g., 06/30/2011)
(e.g., 07/01/2010)
(e.g., 06/30/2011)
Part 5 – Additional Privileges
I authorize the representative listed to perform additional selected acts described below:
Add another representative
Delete a representative
Receive, but not endorse , refund check
O ther acts, specifically described: ____________________________________________________________________________
Individuals Only – Authority To Sign Your Tax Return – You authorize your representative to sign your tax return in the event of
(check all that apply):
Incapacitating disease or injury.
Continuous absence from the United States (including Puerto Rico) for a period of at least 60 days prior to the date required by law
for filing the tax return.
Part 6 – Retention or Revocation of a Prior POA
When you file this POA, you automatically revoke all earlier filed POAs (Part 5 – Additional Privileges) or all tax years or income periods
you indicated (Part 4 – Tax Years or Income Periods Covered by the POA). To expedite your revocation, see instructions.
C heck this box if you want to retain a prior POA. You must attach a copy of any POA you want to remain in effect.
Part 7 – Nontax Issues
(Check all that apply)
Vehicle registration
Court-ordered debt
If you complete this POA for nontax issues only, do not complete the rest of this form. Go to Part 9 – Signatures Authorizing a POA,
sign, and date.
Part 8 – Authorization to Receive Confidential Information Only
C heck this box if you only authorize your representative to receive your confidential information for the specific tax year or
income periods listed below, but not to act as your attorney-in-fact. You cannot select this option if you checked the box in Part 3 –
Authorization for All Tax Years or Income Periods for a Limited Duration.
8A
– Calendar Year (e.g., 2010 or 2010 - 2012)
8B
– Fiscal and Short-Period Income Years (to list additional income years attach a list including all required information to this form)
Year Begins on:
Year Ends on:
Year Begins on:
Year Ends on:
MM/DD/YEAR
MM/DD/YEAR
MM/DD/YEAR
MM/DD/YEAR
Required
Required
Required
Required
(e.g., 07/01/2010)
(e.g., 06/30/2011)
(e.g., 07/01/2010)
(e.g., 06/30/2011)
Part 9 – Signatures Authorizing a POA
If you are a corporate officer, partner, guardian, tax matters representative, executor, receiver, administrator, or trustee on behalf of the
taxpayer(s), you certify you have the authority to execute this by signing the POA on behalf of the taxpayer(s).
Print Name: _________________________________________________________
Date: ______________________________
Signature:
____________________________________________________
Title: ____________________________________
(Individuals – signature must match the name you used in Part 1)
(required for fiduciaries and business entities)
352000091372
FTB 3520 (REV 09-2013) C1 PAGE 2
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