Fillable Minnesota Revenue Power Of Attorney printable pdf download

REV184

Power of Attorney

Read the instructions on the back before completing this form.

Taxpayer’s name (person or business)

Social Security or Minnesota tax ID number (or federal ID number)

Spouse’s name (if a joint return)

Spouse’s Social Security number (if a joint return)

Check one

Street address

(see instructions):

Original—your first power of attorney

authorizing this appointee

City

State

Zip code

Amend—changes an existing power of

attorney for this appointee

Expiration date

Month

Day

Year

(If a date is not provided, this power

Cancel/Revoke—cancels a previously

of attorney is valid until revoked.)

filed power of attorney

I appoint the following as attorney-in-fact to represent me before the Minnesota Department of Revenue. I understand it is my responsibility

to keep my appointee informed of my tax matters and of any matters relating to my nontax debts that have been referred to the department

for collection. I also understand that the department does not send copies of all correspondence to my appointee. (For exception, see “Elec-

tion” below.)

Name of person (appointee) given power of attorney

Name of firm (if applicable)

Street address

City

State

Zip code

Phone number

FAX number

The appointee is authorized to provide and receive private and nonpublic information concerning my state taxes and my nontax debts re-

ferred to the department for collection, and:

I grant full authority to the appointee. The appointee is authorized to perform any and all acts I can perform with respect to my tax mat-

ters and to my nontax debts referred to the Department of Revenue for collection.

Check this box if the appointee is not authorized to sign tax returns.

I grant limited authority for specific tax types, periods and/or duties. Check only the boxes that apply. By checking the boxes, the ap-

pointee will be authorized to perform acts on your behalf with respect to only the indicated tax matters. If a specific year or period is not

indicated for a selected tax type, the powers granted will apply to all years and/or periods, both past and future:

Check this box if the appointee is not authorized to sign the return(s) for the tax matters indicated below.

Tax type

Year(s) or period(s)

Tax type

Year(s) or period(s)

Individual income tax

Sales and use tax

Property tax refund

Withholding tax

Partnership tax

S corporation tax

MinnesotaCare taxes

Corporation franchise

Fiduciary income tax

Nontax debt matters

Other (please specify):

Comments:

Election for appointee to receive all correspondence, including refunds, from the department. If you make this election, you will no longer

receive anything—including refunds, legal notices and correspondence—from the department, and your appointee will receive it all on your

behalf. To make this election, complete and attach Form REV184a to this form.

The power of attorney is not valid until it is signed and dated.

Taxpayer’s signature or signature of corporate officer, partner or fiduciary

Print name (and title, if applicable)

Date

Phone

Spouse’s signature (if joint)

Print spouse’s name (if joint)

Date

Phone

Submit a signed copy of this Power of Attorney to the Department of Revenue using one of the following methods:

• Attach in a secure email to MNDOR.POA@state.mn.us;

• FAX to 651-556-5210; OR

• Mail to Minnesota Revenue, Mail Station 4123, St. Paul, MN 55146-4123

(Rev. 10/12)

Minnesota Revenue Power Of Attorney

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