Form Poa - Power Of Attorney Authorization To Disclose Tax Information Page 2
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4Retention/Withdrawal of Prior Power(s) of Attorney. The filing of this power of attorney automatically withdraws all earlier
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power(s) of attorney on file with the Montana Department of Revenue for the same matters and years or periods covered by this
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document. If you DO NOT want to withdraw a prior power of attorney, check here.
You must attach a copy of any power of attorney you want to remain in effect.
This authorization to disclose taxpayer information does not affect the routine mailing of tax forms, refund checks, original notices
or other original communications, which will continue to be sent only to the taxpayer.
Signature of taxpayer. If a tax matter concerns a year in which a joint return was filed, the husband and wife each file a separate
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power of attorney even if the same representative(s) is(are) appointed. If signed by a corporate officer, partner, guardian, tax
matters partner, executor, receiver, administrator, fiduciary, or trustee on behalf of the taxpayer, I certify that I have the authority to
execute this form on behalf of the taxpayer.
If not signed and dated, this power of attorney will be returned to the taxpayer.
_______________________________________
____________________
__________________________________
Signature
Date
Title (if applicable)
_______________________________________
__________________________________
Print Name
Print name of Taxpayer from Line 1 (if other
than individual)
PART II. Declaration of Representative
I declare that:
I am authorized to represent the taxpayer identified in Part I for the matter(s) specified there; and
I am one of the following:
a. Attorney - licensed to practice law in the jurisdiction shown below.
b. Certified Public Accountant - duly qualified to practice as a certified public accountant in the jurisdiction shown below.
c. Officer - a bona fide officer of the taxpayer’s organization.
d. Full time employee - a full time employee of the taxpayer.
e. Family member - a member of the taxpayer’s immediate family (for example, spouse, parent, child, grandparent, step-parent,
step-child, brother, or sister).
f. Other
If this declaration of representative is not signed and dated, the power of attorney will be returned to the taxpayer.
Representatives must sign in the same order listed in section 2 of part i above. See instructions for Part II.
Designation -
Relationship to Taxpayer
Insert Letter from
Signature
Date
(see instructions for Part II)
Above (a-f)
Filing this Form
Mail or fax the completed form directly to the Montana Department of Revenue:
Montana Department of Revenue
Legal Services, Disclosure Office
125 N. Roberts
PO Box 7701
Helena, MT 59604-7701
Fax: (406) 444-4375
If you are already working with a department employee, please feel free to fax your completed form directly to that person.
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