EFO00104
11-28-12
Idaho State Tax Commission
Power of Attorney
1.
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
2.
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
3.
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) ________________________________
4.
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:
_________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
5.
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): _____________________________
6.
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.