Form Mo 860-1723 - Power Of Attorney - Missouri Department Of Revenue - 2003 Page 2
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1
2SIGNATURE OF, OR FOR, TAXPAYER(S)
I (we) hereby certify that I (we) am (are) the taxpayer(s) named herein or that I have the authority to execute this power of
attorney on behalf of the taxpayer(s). Submission of a DOR-2827, Power of Attorney by a taxpayer will not in itself suffice as an
official notification of a mailing address change with the Department of Revenue.
NAME
TITLE (IF APPLICABLE)
SIGNATURE
DATE
NAME
TITLE (IF APPLICABLE)
SIGNATURE
DATE
DECLARATION OF REPRESENTATIVE
I declare that I am aware of Regulation 12 CSR 10-41.030 and that I am one of the following:
1. a member in good standing of the bar of the highest court of the jurisdiction indicated below;
2. a certified public accountant duly qualified to practice in the jurisdiction indicated below;
3. an officer of the taxpayer organization;
4. a full-time employee of the taxpayer;
5. a fiduciary for the taxpayer;
6. an enrolled agent; or
7. other
and that I am authorized to represent the taxpayer identified above for the tax matters there specified.
Note: All appointed representatives must sign below.
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE)
JURISDICTION (STATE, ETC.)
1.
2.
3.
4.
5.
6.
7.
OTHER __________________________________________________
Please send completed forms to:
Missouri Department of Revenue
Missouri Department of Revenue
Division of Taxation and Collection
Division of Taxation and Collection
P.O. Box 3300
P.O. Box 2200
Jefferson City, MO 65105-3300
Jefferson City, MO 65105-2200
Fax: (573) 522-1722
Fax: (573) 751-2195
(If reporting Business Tax)
(If reporting Personal Tax)
This publication is available upon request in alternative accessible format(s).
MO 860-1723 (11-2003)
DOR-2827 (11-2003)
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