Tax Filing Power of Attorney

1. Taxpayer Information

Full Name Social Security Number / Tax ID Address City State ZIP Code

2. Appointed Representative

Full Name Firm or Organization (if applicable) Address City State ZIP Code Phone Number

3. Tax Matters

Type of Tax Tax Form Number(s) Tax Year(s) or Period(s)

4. Authorization

Scope of Authority Granted

5. Signature

Taxpayer Signature Date Printed Name Title (if applicable)