Power Of Attorney And Declaration Of Representative Page 2

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Page 2
Gen. 58
Web-Fill
7-12
5 e-Business Center Account - Your tax representative can create an e-Business Center account with the Department of Revenue to perform
online services on behalf of your business. The online services offered through the e-Business Center include filing a return and paying tax for
certain business tax types, viewing online tax history, and managing tax payment information. Please select the Electronic Services tab on the
Department’s homepage for a list of the online services for businesses that require login to the e-Business Center.
PLEASE CHECK THIS BOX IF YOUR REPRESENTATIVE WILL CREATE AN e-BUSINESS CENTER ACCOUNT TO PERFORM ONLINE
SERVICES ON YOUR BEHALF .......................................................................................................................................................................................
6 Retention/Revocation of Prior Power(s) of Attorney. - The filing of this power of attorney automatically revokes all earlier power(s) of
attorney on file with the Department of Revenue for the same tax matters and years or periods covered by this document. If you do not
want to revoke a prior power of attorney, check here ................................................................................................................................................
YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.
7 Signature of Taxpayer(s). - If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested.
If signed by a corporate officer, partner, guardian, tax matters partner/person, executor, representative, receiver, administrator, 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.
Signature
Date
Title (if applicable)
Print Name
Signature
Date
Title (if applicable)
Print Name
Part 2.
Declaration of Representative
Under penalties of perjury, I declare that:
I am authorized to represent the taxpayer(s) identified in Part 1 for the tax matter(s) specified there; and
I am one of the following:
a Attorney - a member in good standing of the bar of the highest court of the jurisdiction shown below.
b Certified Public Accountant - duly qualified to practice as a certified public accountant in the jurisdiction shown below.
c Enrolled Agent - Enrolled as an agent under the requirements of Treasury Department Circular No. 230.
d Officer - a bona fide officer of the taxpayer’s organization.
e Full-Time Employee - a full-time employee of the taxpayer.
f Family Member - a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister).
g Other (explain) -
IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE RETURNED.
Jurisdiction (state) or
Designation - Insert
Signature
Date
Enrollment Card No.
above letter (a-g)

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