Michigan Department of Treasury
36
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3683 (Rev. 8-09)
Payroll Service Provider Combined Power of Attorney Authorization
and Corporate Officer Liability (COL) Certificate for Businesses
Issued under authority of the Revenue Act, P.A. 122 of 1941, as amended. Filing is voluntary.
Complete this form if you wish to appoint someone to represent your business to the State of Michigan for withholding tax matters.
Taxpayer Name
Account No./Federal Employer ID No. (FEIN)
Address (Street or RR#)
City, State, ZIP Code
Contact Person
Telephone Number
Payroll Service Name
Address (Street or RR#)
City, State, ZIP Code
Contact Person
Telephone Number
Effective _________________________ (mo/day/yr), the above-named payroll service provider/individual is authorized to
represent my business and receive information in reference to all Treasury income tax withholding matters until I notify the
Michigan Department of Treasury in writing that this Power of Attorney is revoked.
Taxpayer's Power of Attorney Authorization
Must be signed by an authorized representative of the business. I certify that I have the authority to execute this Power of Attorney.
Signature
Date
Type or Print Name
Title
Please be aware of officer, member or partner liability as provided in Michigan Compiled Laws 205.27a(5):
"If a corporation, limited liability company, limited liability partnership, partnership, or limited partnership liable for taxes
administered under this act fails for any reason to file the required returns or pay the tax due, any of its officers,
members, managers, or partners who the department determines, based on either an audit or an investigation, have
control or supervision of, or responsibility for, making the returns or payments is personally liable for the failure......."
CERTIFICATION
Corporations, partnerships, LLP's or LLC's must complete this section before this form can be processed. This officer, member or partner certification
must be resubmitted when there is a change in the individual responsible for filing and/or paying Michigan taxes.
Signature of Corporate Officer, Partner, or Member responsible for reporting and/or paying Michigan taxes
Date
Type or Print
Title
If you have any questions, please contact the Michigan Department of Treasury at (517) 636-4660. You may fax
this form to (517) 636-4520, or mail to:
Michigan Department of Treasury
P.O. Box 30778
Lansing, MI 48909-8278