Form Poa - Power Of Attorney Authorization To Disclose Tax Information
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1
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4CLEAR FORM
MONTANA
POA
Power of Attorney
Rev 01 13
Authorization to Disclose Tax Information
Please type or print. See the separate instructions.
PART I
Caution! Each taxpayer must complete a separate power of attorney form.
This form will not be honored for any purpose
other than representation before the Department of Revenue.
Notice: The department will accept Federal Form 2848 as creating a power of attorney for representation before the Department
of Revenue if the form is completed and in Part I, Section 3, Matters, the taxpayer identifies “Montana” and the type of tax, tax form
number, and year(s) or period(s) that the representative is authorized to discuss with the Department of Revenue. If completing the
federal form, a copy must be provided to the Department of Revenue.
1.
Taxpayer Information. Taxpayer must sign and date this power of attorney on page 2, section 6.
Taxpayer Identification Number(s)
Taxpayer Name and Address
Telephone Number
hereby appoints the following representative(s) as attorney(s)-in-fact:
2.
Representative(s) must sign and date this form on page 2, Part II. If you are a representative and want to withdraw from an
existing power of attorney form previously filed with the Department of Revenue, simply write WITHDRAW across the top of the
form, sign the form in Part II, and file the form as indicated on the bottom of page 2.
Name and Address
PTIN
Telephone Number
FAX Number
Email Address
Name and Address
PTIN
Telephone Number
FAX Number
Email Address
to represent the taxpayer before the Montana Department of Revenue for the following matters:
3.
Tax Matters and Tax Years Covered by this Form
Your representative is authorized to inspect, receive and discuss confidential information for the tax types and tax years you
authorize by checking the appropriate boxes below and inserting the exact tax years. You may include only future tax periods that
end no later than three years after the date the form was received by Department of Revenue. If tax matters and tax periods are
not specified, this written authorization will not be in effect.
Insert exact tax years
Insert exact tax years
q Individual Income Tax
q
_________________
Rental Vehicle Tax
___________________
Withholding Tax
q Corporation License Tax
q
_________________
___________________
q S Corporation
q
_________________
Lodging Facilities Tax
___________________
q Partnership
q
_________________
Combined Oil and Gas Tax
___________________
q
Other, please specify
___________________
4.
Acts Authorized by This Form
Check the box that best describes what authorization you are delegating to your representative.
Representation. Department employees can provide confidential tax information to the representative and discuss the
q
information. (This is the most frequent response.)
Information sharing. Department employees can provide confidential tax information to the representative, but cannot
q
discuss the information.
Decision making authority. Department employees can provide confidential information to a representative, can discuss
q
the information and the representative can act on the taxpayer’s behalf for all purposes, including settlement and waiver of
appeal rights.
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