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TBOR 1
Department of
Rev. 8/10
Taxation
Reset Form
P.O. Box 1090
Columbus, OH 43216-1090
Declaration of Tax Representative
Taxpayer’s name
Business name
Address
City
State
ZIP code
FEIN or Social Security number
(Only use Social Security number if requesting individual income tax representative or if business does not have a FEIN.)
Representative Information
Representative’s name and fi rm
Address
City
State
ZIP code
Telephone number
Fax number
E-mail address
Authorized Signature
The taxpayer identifi ed above authorizes the representative identifi ed above to represent the
taxpayer before the Department of Taxation. This authorization includes the authority to view and receive copies of returns,
reports or other documents fi led by the taxpayer or prepared by the Department of Taxation concerning the business,
property or transactions of the taxpayer, request alternative methods of taxation, present evidence or legal arguments to
any employee of the Department of Taxation, raise objections to audit fi ndings or assessments, fi le petitions or applications
and waive statutes of limitation. This authorization does not authorize the tax representative to sign any form or declaration
where the Ohio Revised Code specifi cally requires that the form or declaration be signed by the taxpayer. The taxpayer
understands that the acts of the authorized representative may increase or decrease the taxpayer’s tax liabilities
and legal rights. The taxpayer must indicate all restrictions, if any, to this authorization in the space below.
I certify, under penalties of perjury, that I am the taxpayer or that I am a corporate offi cer, LLC member, general partner,
guardian, tax manager or similar employee authorized to act on tax matters, executor, receiver, administrator or trustee
on behalf of the taxpayer and that I have the authority to execute this form on behalf of the taxpayer. If this form is not
properly completed, this Declaration of Tax Representative will not be processed.
Signature
Date
Name (print)
Title
Telephone number
Fax number
Restrictions to this Declaration
The following restrictions are placed on this Declaration of Tax Representative:
Expiration Date
This declaration is valid until
. If no expiration date is given, this declaration will
expire one year after the date that it is signed.
Send this declaration to: Ohio Department of Taxation, Compliance Division - TBOR 1, P.O. Box 1090, Columbus, OH 43216-
1090, or fax to (614) 387-1847. (Use same address to revoke declaration.)