Form Par 101 - Virginia Power Of Attorney And Declaration Of Representative Page 2
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4LINE 4 Electronic Notices and Communications
I request that representative(s) listed on this form receive copies of e-mail communication. ..................................................................
Note: Copies of e-mail communications will be furnished through US Postal Service mail.
LINE 5 Acts authorized - The representatives are authorized to receive and inspect confidential tax information and to perform any and
all acts that I (we) can perform with respect to the tax matters described on line 3. The authority does not include the power to receive
refund checks, the power to substitute another representative, the authority to execute a request for a tax return, the power to sign certain
returns, or the power to consent to a disclosure of tax information.
This Power of Attorney and Declaration of Representative revokes all previous Powers of Attorney and Declaration of Representative and
Powers of Attorney and Releases received by the Virginia Department of Taxation for the matters and years or periods covered by this
form, except the following:
(Specify to whom granted, date and address including ZIP code, and attach copies of earlier power(s) and authorizations.)
LINE 6 Signature of taxpayer(s) - If a tax matter concerns a joint return, both husband and wife must sign if joint representation is
requested. If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf
of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.
___________________________________
____________________________________________
_______________________
Signature
Title, if applicable
Date
___________________________________
Print Name
___________________________________
____________________________________________
_______________________
Signature
Title, if applicable
Date
___________________________________
Print Name
LINE 7 - Declaration and Signature of Representative
Declaration of Representative - Under penalties of perjury, I declare that:
I am authorized to represent the taxpayer(s) identified on line 1 for the tax matter(s) specified on line 3; and
I am one of the following:
a
Attorney—a member in good standing of the bar of the highest court of the jurisdiction shown below.
Certified Public Accountant—duly qualified to practice as a certified public accountant in the jurisdiction shown below.
b
c
Enrolled Agent—licensed by the Internal Revenue Service to represent taxpayers before the IRS.
Officer—a bona fide officer of the taxpayer’s organization. Title: _____________________________
d
e
Full-Time Employee—a full-time employee of the taxpayer. Title or Position: _____________________________
Family Member—a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister).
f
g
Other (explain)
Signature of representative(s) - Each representative must sign and date below.
Designation -
Jurisdiction (state)
Virginia Authorized Agent
Insert above
or Enrollment Card
Signature
Date
Number (If applicable)
letter (a–g)
No. (if applicable)
A -
A -
IF THIS PAR 101 POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE
IS NOT SIGNED AND DATED OR LACKS COMPLETE INFORMATION, IT WILL BE RETURNED.
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