Kansas Department Of Revenue Power Of Attorney
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1
2KANSAS DEPARTMENT OF REVENUE
POWER OF ATTORNEY
1. T
. Include spouse's name if this is for a joint return. If the taxpayer is a business, enter both its legal name and
AXPAYER INFORMATION
its trade or DBA name. Both the person granting and the person being granted the power of attorney must sign and date this form
below in Sections 3 and 4. (If you have any questions about how to complete this form, please see the instructions on the back).
Taxpayer's Name. (If a business include both legal name and dba name.)
Taxpayer’s Social Security #
Address
City
State
Zip Code
EIN/SSN/PTIN
Spouse's Name
Spouse’s Social Security #
Address (if different)
City
State
Zip Code
Area Code & Phone Number
2. T
.
AXPAYER GRANT OF POWER OF ATTORNEY
I
,
,
-
-
:
HEREBY APPOINT THE FOLLOWING ATTORNEY
ACCOUNTANT
OR OTHER REPRESENTATIVE AS MY ATTORNEY
IN
FACT
Representative's name and title. If a member of a firm, enter both the representative's name and the firm name.
Phone number
Address
Fax number
City, State, Zip Code
EIN/SSN/PTIN
Representative's name and title. If a member of a firm, enter both the representative's name and the firm name.
Phone number
Address
Fax number
City, State, Zip Code
EIN/SSN/PTIN
T
K
D
R
:
O REPRESENT ME BEFORE THE
ANSAS
EPARTMENT OF
EVENUE FOR THE FOLLOWING TAX MATTERS
Type of Tax (Individual Income, Sales, Withholding, etc.)
Tax Year(s) or Period(s)
A
A
. For the tax types and periods listed, the representative(s) are authorized to (check all applicable boxes):
UTHORIZED
CTS
1
1
Receive and inspect my confidential tax information.
Sign any agreement, consent, or other document on my
1
behalf.
Represent me in tax matters before the department.
1
Perform any act that I can perform with respect to the tax
matter listed above.
List any specific addition or deletion to the acts that are otherwise authorized in this power of attorney. See Instructions.
Retention/revocation of prior Powers of Attorneys.
I hereby revoke all earlier powers of attorney on file with the Kansas Department of Revenue for the same tax matters and
periods covered by this document.
1
Check this box if you DO NOT wish to revoke a prior power of attorney. You must attach a copy of any
power of attorney you want to remain in effect.
S
. If a tax matter concerns a joint return, both the husband and wife must sign when joint
3.
IGNATURE OF TAXPAYER OR TAXPAYERS
representation is requested. When a corporate officer, partner, guardian, executor, receiver, administrator, or trustee signs
this section on behalf of a taxpayer, the signatory also certifies that the signatory is authorized to execute this form on behalf
of the taxpayer.
_______________________________________________________
________________________________________________
________________________
(Signature)
(Printed Name)
(Date)
_________________________________________________________
________________________________________________
________________________
(Signature)
(Printed Name)
(Date)
4.
S
.
IGNATURE OF REPRESENTATIVE OR REPRESENTATIVES
_________________________________________________________
________________________________________________
________________________
(Signature)
(Printed Name)
(Date)
_________________________________________________________
________________________________________________
________________________
(Signature)
(Printed Name)
(Date)
DO-10
Rev. 7/10
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