Form Poa - 1 - Power Of Attorney (2009)
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1
2POA - 1
Indiana Department of Revenue
State Form 49357
POWER OF ATTORNEY
(R2 / 9-09)
(Instructions on Back)
1)
2)
Taxpayer(s) Name(s)
Indiana Taxpayer Identification Number
D\B\A Name(s)
Employer Identification Number
Address
City
Social Security Number
State
Zip Code
Spouse’s Social Security Number
Telephone #
Hereby appoint(s) the following :
3)
Individual Representative Name
Additional Individual Representative Name
Address
Address
City
State
Zip Code
City
State
Zip Code
Telephone #
Telephone #
4)
Firm/Corp. Name (If applicable)
If Firm or Corp. list Representative(s) Name
a)
Address
b)
City
State
Zip Code
c)
Telephone #
d)
5)
Type of Tax
Tax Form Number
Year(s) / Period(s)
(Income, Withholding, Sales, etc.)
(IT-40, WH-3, ST-103, etc.)
____________________________
__________________________
________________________
____________________________
__________________________
________________________
____________________________
__________________________
________________________
6)
I acknowledge that the designated representative has the authority to receive confidential information and full power to perform on behalf of
the taxpayer in tax matters related to this Power of Attorney. This authority does not include the power to receive refund checks.
I acknowledge that actions taken by the designated representative are binding, even if the representative is not an attorney. Proceedings can-
not later be declared legally defective because the representative was not an attorney.
If I am a corporate officer, partner or fiduciary acting on behalf of the taxpayer, I certify that I have authority to execute this Power of Attorney
on behalf of the taxpayer.
7)
Signature _________________________________________________
Date _______________________________
Printed Name ______________________________________________
Title _____________________________________________________
Telephone # _________________________
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