Power Of Attorney And
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2REV-677 LE (08-12)
POWER OF ATTORNEY AND
DECLARATION OF
REPRESENTATIVE
GENERAL INSTRUCTIONS:
This form provides limited authority for department representatives to speak about confidential tax matters with designated third parties. Such
authority is limited to the tax period, tax type and the specific issue/purpose identified herein.
While tax practitioners are encouraged to maintain appropriate declarations of authority to handle clients' tax matters within their
own records, tax practitioners should not submit unsolicited REV-677 forms to the department en masse or as a matter of routine.
Such forms will be disregarded.
A REV-677 form should only be submitted to an individual within the department upon an agent's request for such authorization.
If a department representative has requested a REV-677 form to authorize discussion of confidential tax matters with a third party, please return
the form to the department representative as requested.
PART I
Power of Attorney
NOTE: An organization, firm or partnership may not be designated as a taxpayer’s representative.
The following taxpayer
START
Taxpayer Name
Identifying Number
Address
City
State
ZIP
hereby appoints
Appointee Name(s)
Telephone Number
Address
City
State
ZIP
as attorney-in-fact to represent the taxpayer before any office of the PA Department of Revenue for the following tax matter(s). Specify the
type(s) of tax, tax year(s) or period(s), tax return/report at issue and the specific purpose for which authorization to discuss confidential tax
matters with a third-party is sought.
Type(s) of tax
Tax Year(s) or Period(s)
Tax Return/Form
Purpose for Authorization
The attorney-in-fact is authorized, subject to revocation, to receive confidential information and perform any and all acts the principal can perform
with respect to the above-specified tax matters, excluding the power to receive refund checks and the power to sign the return, unless specifically
granted below.
Initial here
to grant the power to receive – but not to endorse or cash – refund checks for the above-referenced tax matters to
the appointee named above.
Only if this form is being submitted to the department in response to an audit, provide an address below to which copies may be sent of notices
and other written communications addressed to the taxpayer in proceedings involving the above-specified tax matters.
Appointee Name(s)
Telephone Number
Address
City
State
ZIP
This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the PA Department of Revenue for the
same matters and years or periods covered by this power of attorney, except the following:
MM/DD/YYYY
Granter Name
Date
Refer to attached copies of
earlier powers and authorizations
Address
City
State
ZIP
Signature of or for taxpayer
If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer, such party certifies he/she has the authority to execute this power
of attorney on behalf of the taxpayer.
MM/DD/YYYY
Signature
Title
Date
PLEASE SIGN AFTER PRINTING.
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