Form Poa-1 - Power Of Attorney - Indiana Department Of Revenue
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1INDIANA DEPARTMENT OF REVENUE
POA - 1
Rev. 3/07
POWER OF ATTORNEY
SF 49357
(Instructions on Back)
1)
2)
Taxpayer(s) Name(s)
Indiana Taxpayer Identifi cation Number
D\B\A Name(s)
Employer Identifi cation Number
Address
Social Security Number
City
State
Zip Code
Spouse's Social Security Number
(
)
Telephone #
Hereby appoint(s) the following :
Individual Representative Name
Additional Individual Representative Name
3)
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)
(
)
d)
Telephone #
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 confi dential 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 cannot later
be declared legally defective because the representative was not an attorney.
If I am a corporate offi cer, partner or fi duciary 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
Title
Telephone # (
)
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