Form Dor-2827 - Missouri Department Of Revenue Power Of Attorney Page 2
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2SIGNATURE OF, OR FOR, TAXPAYER(S)
I (we) hereby certify that I (we) am (are) the taxpayer(s) named herein or that I have the authority to execute this power of
attorney on behalf of the taxpayer(s).
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NAME
TITLE (IF APPLICABLE)
SIGNATURE
DATE
TAXPAYER TELEPHONE NUMBER
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NAME
TITLE (IF APPLICABLE)
SIGNATURE
DATE
TAXPAYER TELEPHONE NUMBER
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DECLARATION OF REPRESENTATIVE
Please consult Missouri Regulation 12 CSR 10-41.030 for any questions about who may serve as an attorney(s)-in-fact and
what additional documentation may be required.
I declare that I am aware of Regulation 12 CSR 10-41.030 and 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. a certified public accountant duly qualified to practice in the jurisdiction indicated below;
3. an officer of the taxpayer organization;
4. a full-time employee of the taxpayer;
5. a fiduciary for the taxpayer;
6. an enrolled agent;
7. tax preparer; or
8. other authorized representative or agent
and that I am authorized to represent the taxpayer(s) identified above for the tax matters there specified.
Note: All appointed representatives must sign below.
No digital signatures allowed
NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
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DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE)
JURISDICTION (STATE, ETC.)
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NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
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DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE)
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JURISDICTION (STATE, ETC.)
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NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
DATE
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DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE)
JURISDICTION (STATE, ETC.)
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NAME OF REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE
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DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE)
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JURISDICTION (STATE, ETC.)
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Please send completed forms to:
Missouri Department of Revenue
Missouri Department of Revenue
Missouri Department of Revenue
Missouri Department of Revenue
Taxation Division
Taxation Division
Taxation Division
Taxation Division
PO Box 357
PO Box 2200
PO Box 300
PO Box 811
Jefferson City, MO 65105-0357
Jefferson City, MO 65105-2200
Jefferson City MO 65105-0300
Jefferson City MO 65105-0811
Fax: (573) 522-1722
Fax: (573) 751-2195
Fax: (573) 522-1720
Fax: (573) 522-1720
(If reporting Business Tax)
(If reporting Personal Tax)
(If reporting Motor Fuel Tax)
(If reporting Cigarette Tax or
Other Tobacco Products Tax)
DOR-2827 (07-2012)
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