Power Of Attorney And Page 2

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If the power of attorney is granted to a person other than an attorney or certified public accountant, the taxpayer's signature must be witnessed
or notarized below.
The person signing as or for the taxpayer (check and complete one):
is known to and signed in the presence of the two disinterested witnesses whose signatures appear here:
PLEASE SIGN AFTER PRINTING.
(Signature of Witness)
(Date)
MM/DD/YYYY
PLEASE SIGN AFTER PRINTING.
(Signature of Witness)
(Date)
MM/DD/YYYY
appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.
PLEASE SIGN AFTER PRINTING.
Witness
NOTARIAL SEAL
(Signature of Notary)
(Date)
MM/DD/YYYY
PART II
Declaration of Representative
I declare that I am one of the following:
1
a member in good standing of the bar of the highest court of the jurisdiction indicated below;
2
duly qualified to practice as a certified public accountant in the jurisdiction indicated below;
3
a bona fide officer of the taxpayer organization;
4
a full-time employee of the taxpayer;
5
a member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);
6
a fiduciary for the taxpayer; and/or
7
Other (specify)
;
and that I am authorized to represent the taxpayer identified in Part I for the tax matters specified therein.
DESIGNATION
JURISDICTION
(INSERT APPROPRIATE NUMBER
(STATE, ETC.)
SIGNATURE
DATE
FROM ABOVE LIST)
MM/DD/YYYY
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
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