IRS Power of Attorney and Declaration of Representative (Form 2848)

1. Taxpayer Information

Name(s) and address

Taxpayer Identification Number(s)

Daytime telephone number

Plan number (if applicable)

Name and Address	CAF No.	PTIN	Telephone No.	Fax No.	Check if New

List any specific acts you authorize (see instructions):

Type of Tax (Income, Employment, Payroll, etc.)	Tax Form Number	Year(s) or Period(s)

If you do not want to revoke a prior power of attorney, check here: Specify to whom power of attorney is granted:

Signature

Date

Title (if applicable)

Print Name

(To be completed by the representative.)

Designation — Insert above letter (a–r)	Licensing jurisdiction (state) or other licensing authority	Bar, license, certification, registration, or enrollment number	Signature	Date