Fillable Form R-7006 - Power Of Attorney And Declaration Of Representative (Page 2 of 2) in pdf

R-7006 (1/11)

Page 2

NOTICES AND COMMUNICATIONS. Original notices and other written communications will be sent only to you, the taxpayer. Your representa-

tive may request and receive information by telephone, e-mail or fax. Upon request, the representative may be provided with a copy of a notice

or communication sent to you. If you want the representative to request and receive a copy of notices and communications sent to you, check

this box.

■

REVOCATION OF PRIOR POWER(S) OF ATTORNEY. Except for Power(s) of Attorney and Declaration of Representative(s) filed on Form

R-7006 (1/11), the filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Louisiana Department

of Revenue for the same tax matters and years or periods covered by this document.

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 tax-

payer, I certify that I have the authority to execute this form on behalf of the taxpayer.

IF THIS POWER OF ATTORNEY IS NOT SIGNED AND DATED, IT WILL BE RETURNED.

_____________________________________________________________________________________

____________________

Taxpayer signature

Date

_____________________________________________________________________________________

____________________

Spouse signature

Date

_________________________________________________

__________________________________

____________________

Signature of duly authorized representative, if the taxpayer

Title

Date

is a corporation, partnership, executor or administrator

Part II. DECLARATION OF REPRESENTATIVE

Under penalties of perjury, I declare that:

• I am not currently under suspension or disbarment from practice before the Internal Revenue Service.

• I am authorized to represent the taxpayer(s) identified in Part I for the tax matters specified there; and

• I am one of the following: (insert applicable letter in table below)

a. Attorney—a member in good standing of the highest court of the jurisdiction shown below.

b. Certified Public Accountant—duly qualified to practice as a certified public accountant in the jurisdiction shown below.

c. Enrolled Agent—a person enrolled to practice before the Internal Revenue Service.

d. Officer—a bona fide officer of the taxpayer organization.

e. Employee—an employee of the taxpayer.

f. Family Member—a member of the taxpayer’s immediate family (state the relationship, i.e., spouse, parent, child, brother, or sister).

_____________________________________________________________________________.

g. Other (state the relationship, i.e., bookkeeper or friend) ________________________________________________.

h. Former Louisiana Department of Revenue Employee. As a representative, I cannot accept representation in a matter with which I

had direct involvement while I was a public employee.

IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE RETURNED.

State

Designation-Insert

Issuing

State License Number

Signature

Date

Above Letter (a-h)

License

Form R-7006 - Power Of Attorney And Declaration Of Representative Page 2

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