Form 150-800-005 - Tax Information Authorization And Power Of Attorney For Representation
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Tax Information Authorization
and
For Office Use Only
Power of Attorney for Representation
Date received
• Please print. • Use only blue or black ink. • See additional information on the back.
Taxpayer name
Identifying number (SSN, BIN, FEIN, etc.)
Spouse’s/registered domestic partner’s (RDP) name, if joint return
Spouse’s/RDP’s identifying number (SSN, etc.)
Address
City
State
ZIP code
Check only one:
Tax Information Authorization: Checking this box allows the department to disclose your confidential tax information to your
designee. You may designate a person, agency, firm, or organization.
Power of Attorney for Representation: Check this box if you want a person to “represent” you. This means the person may
receive confidential information and may make decisions on your behalf. The person you designate must meet the qualifications
listed on the back of this form.
For
All tax years, or
Specific tax years: __________________________________________________________________ ,
I hereby appoint the following person as designee or authorized representative:
Name
Telephone number
Fax number
(
)
(
)
Mailing address
City
State
ZIP code
Representative’s title and Oregon license number or relationship to taxpayer
If out-of-state CPA, sign here attesting you meet the requirements to practice in Oregon (see instructions)
The above named is authorized to receive my confidential tax information and/or represent me before the Oregon Department of Revenue for:
All tax matters, or
Specific tax matters.
Enter tax program name(s): ________________________________________________________________________
Signature of Taxpayer(s)
• I acknowledge the following provision: Actions taken by an authorized representative are binding, even if the representative is
not an attorney. Proceedings cannot later be declared legally defective because the representative was not an attorney.
• Corporate officers, partners, fiduciaries, or other qualified persons signing on behalf of the taxpayer(s): By signing, I also certify
that I have the authority to execute this form.
• If a tax matter concerns a joint return, both spouses/RDPs must sign if joint representation is requested. Taxpayers filing jointly
may authorize separate representatives.
Signature
Print name
Date
X
Daytime telephone number
Title (if applicable)
(
)
Spouse/RDP (if joint representation)
Print name
Date
X
Note: This authorization form automatically revokes and replaces all earlier tax authorizations and/or all earlier powers of attorney
on file with the Oregon Department of Revenue for the same tax matters and years or periods covered by this form. If you do not
want to revoke a prior authorization, initial here ______.
Attach a copy of any other tax information authorization or power of attorney you want to remain in effect.
Please complete the following, if known (for routing purposes only):
Send to: Oregon Department of Revenue
Revenue Employee: _________________________________________________
955 Center St NE
Division/Section: ____________________________________________________
Salem OR 97301-2555
Telephone/Fax: ______________________________________________________
If this tax information authorization or power of attorney form is not signed, it will be returned.
150-800-005 (Rev. 12-10)
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