Form A-222 - Power Of Attorney
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Power of Attorney
Form
Wisconsin Department
A-222
See instructions on reverse side
of Revenue
(Please print or type)
Taxpayer Name
Spouse Name
Social Security Number(s)
Wisconsin Tax Account Number
Part 1
Taxpayer Address (number and street)
Spouse Address
Federal Identification Number
Telephone Number – Daytime
(if different from taxpayer)
(
)
City, State, and Zip Code
City, State, and Zip Code
E-mail Address
Part 2
Hereby appoint(s) the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before the Department of
Revenue for the tax matter(s) specified in Part 3.
Name
Firm Name/Address
Telephone Number
**
(
)
(
)
(
)
**
Designated Receiver
Part 3
Type of Tax
Tax Year(s) or Period(s) Covered
Individual Income Tax . . . . . . . . . . . . . . . . . . .
Corporation Franchise or Income Tax . . . . . .
Excise Tax . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sales or Use Tax . . . . . . . . . . . . . . . . . . . . . .
Withholding Tax . . . . . . . . . . . . . . . . . . . . . . .
Other
(list type of tax/matter)
All delinquent tax matters . . . . . . . . . . . . .
Part 4
Complete if Power of Attorney is limited to:
Field/office audit matters
Appeal of notice dated
Other
Send notices and other written communications to:
Attorney-in-fact
OR
Taxpayer
► I understand, agree, and accept:
Part 5
If the Attorney-in-fact box is checked, any notices and written communications will be sent to only the attorney-in-fact, except as required
by statute. If the Taxpayer box is checked, any notices and written communications will be sent to only the taxpayer. Notice to the attorney-
in-fact is notice to the taxpayer and vice versa. If no box is checked or both boxes are checked, any notices and written communications
will be sent only to the taxpayer.
Part 6
The Power of Attorney revokes all prior Powers of Attorney on file with the Wisconsin Department of Revenue with respect to
the same matters and years or periods covered by this instrument, except the following:
(Specify to whom granted, date, and address, or refer to attached copies of prior powers of attorney)
Part 7
I understand that the execution of this Power of Attorney does not relieve me of personal responsibility for correctly and
timely reporting and paying taxes, or from the penalties for failure to do so, all as provided for under Wisconsin tax law.
I understand a photocopy and/or faxed copy of this form has the same authority as the signed original.
If signed by a corporate officer, partner, or fiduciary on behalf of the taxpayer, I certify that I have the authority to execute this Power
of Attorney on behalf of the taxpayer.
Signature
Title
Date
Signature
Title
Date
This Power of Attorney is not valid unless signed by the individual(s), corporate officer, partner or fiduciary.
Refer to instructions on reverse side.
A-222 (R. 6-12)
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