Declaration Of Tax Representative
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1Form TBOR-1
Rev. 3/01
P.O. Box 530
h
Columbus, OH 43216-0530
D
T
R
ECLARATION OF
AX
EPRESENTATIVE
Taxpayer’s Name ________________________________________________________________________________________
DBA __________________________________________________________________________________________________
Address _______________________________________________________________________________________________
City _________________________________________________
State _____________
Zip Code ________________
FEIN or Social Security No.
__________________________________________________________________________
______
(only use Social Security Number if requesting Individual Income Tax representative or if business does not have a FEIN)
Representative Information
Representative’s Name & Firm _______________________________________________________________________________
Address __________________________________________________________________________________________________
City _________________________________________________
State _____________
Zip Code ___________________
Telephone Number ___________________________________
Fax Number ______________________________________
E-mail Address ____________________________________________________________________________________________
Authorized Signature The taxpayer identified above authorizes the representative identified above to represent the tax-
payer before the Department of Taxation. This authorization includes the authority to view and receive copies of returns,
reports or other documents filed by the taxpayer or prepared by the Department of Taxation concerning the business, property
or transactions of the taxpayer, request alternative methods of taxation, present evidence or legal arguments to any employee
of the Department of Taxation, raise objections to audit findings or assessments, file petitions or applications and waive
statutes of limitation. This authorization does not authorize the tax representative to sign any form or declaration where the
Ohio Revised Code specifically requires that the form or declaration be signed by the taxpayer. The taxpayer understands
that the acts of the authorized representative may increase or decrease the taxpayer’s tax liabilities and legal rights.
The taxpayer must indicate all restrictions, if any, to this authorization in the space below.
I certify, under penalties of perjury, that I am the taxpayer or that I am a corporate officer, LLC member, general partner,
guardian, tax manager or similar employee authorized to act on tax matters, executor, receiver, administrator, or trustee on
behalf of the taxpayer and that I have the authority to execute this form on behalf of the taxpayer. If this form is not properly
completed, this Declaration of Tax Representative will not be processed.
Signature ____________________________________________________________________ Date _______________________
Name (print) ____________________________________________________ Title ______________________________________
Telephone Number _______________________________________ Fax Number ______________________________________
Restrictions to this Declaration The following restrictions are placed on this Declaration of Tax Representative :
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Expiration Date
This Declaration is valid until ______________________. If no expiration date is given, this Declaration
will expire one year after the date that it is signed.
Send this declaration to: Ohio Department of Taxation, Office of Chief Counsel – TBOR-1, P.O. Box 530. Columbus, OH
43216-0530, or fax to (614) 466-7979. (Use same address to revoke declaration.)
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