Tax Filing Power of Attorney Form

1. Taxpayer Information

Name

Taxpayer Identification Number

Address

City

State

ZIP Code

2. Representative Information

Name

Firm/Company

Address

City

State

ZIP Code

Phone

Email

3. Tax Matters

Tax Type(s)

Years or Periods

4. Acts Authorized

5. Revocation of Prior POA

6. Signature and Declaration

Taxpayer Signature

Date

Representative Signature

Date