Idaho State Tax Commission Power Of Attorney

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EFO00104

11-28-12

Idaho State Tax Commission

Power of Attorney

TAXPAYER INFORMATION

*Last name or company legal name

*Your first name/middle initial

*SSN or EIN

*Spouse’s last name

*Spouse’s first name/middle initial

*Spouse’s SSN

*Address

Daytime telephone number

*City, State, Zip

E-mail address

REPRESENTATIVE(S) - For multiple representatives, attach additional sheets.

*Name

PTIN, EIN or SSN

*Firm or company’s legal name

Telephone number

*Address

Fax number

*City, State, Zip

E-mail address

TAX MATTERS APPROVED FOR REPRESENTATION

The above representative is hereby appointed as attorney-in-fact to represent the taxpayer(s) before the Idaho Tax Commission for the following tax

matter(s). You must identify the tax type, permit number (if applicable), and tax periods.

*Tax Types

*State Tax Permit Number

*Tax Periods/Years

(Required if applicable)

Individual income tax

Business income tax

Sales & use tax

Income tax withholding

Other tax (specify) ________________________________

ACTIONS AUTHORIZED

The representative(s) are authorized to receive and inspect confidential tax information and records, as well as perform any and all actions that the

taxpayer(s) named above can perform with respect to the specified tax matters listed. The authority doesn’t include the power to receive refund checks.

Added or deleted actions - List any specific additions or deletions to the actions otherwise authorized in this Power of Attorney:

_________________________________________________________________________________________________________________________

__________________________________________________________________________________________________

REVOCATION/EXPIRATION

The filing of this Power of Attorney (POA) automatically revokes all prior POAs on file with the Tax Commission for the same matters and tax years

authorized in this document.

Check here if you don’t want to revoke prior POA(s):

Expiration date (optional): _____________________________

SIGNATURE OF TAXPAYER(S)

All parties identified in Section 1 MUST sign.

If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf of the taxpayer; I certify that

I have the authority to execute this form.

*Name

Title (If applicable)

Date

*Name

Title (If applicable)

Date

Required Information.

This form is valid only if all information is complete. An incomplete form will be returned to you.