Power Of Attorney And Declaration Of Representative printable pdf download

Power Of Attorney And Declaration Of Representative

City of Chicago

Department of Revenue

Power of Attorney and

Declaration of Representative

PART I. - Power of Attorney

Taxpayer(s} name, identifying number, and address including ZIP code (Please type or print)

hereby appoints (name(s), address(es), including ZIP code(s), telephone number(s} and email address(es) of individual(s))*

Type of Tax

Year(s} or Period(s)

The attorney(s)-in-fact (or either of them) are authorized, subject to revocation, to receive confidential information and to perform

any and all acts that the principal(s) can perform with respect to the above specified tax matters (excluding the power to receive

refund checks, and the power to sign the return, unless specifically granted below).

Send copies of notices and other written communications addressed to the taxpayer(s) in proceedings involving the above tax matters

to:

1 (

the appointee first named above, or

2 (

(names of not more than two of the above named appointees)

Initial here ••.......... if you are granting the power to receive, but not to endorse or cash, refund checks for the above tax matters to:

3 (

the appointee first named above, or

4 (

(name of one of the above designated appointees)

This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the Department of

Revenue for the same tax matters and years or periods covered by this power of attorney, except for the following:

(Specify to whom granted,

date, and address inclnding

ZIP code, or refer to attached

copies of earlier powers and authorizations.)

Signature of or for taxpayers(s)

(If signed by a corporate

officer, partner,

or fiduciary on behalf of the taxpayer, I certify that I have the authority

execute this power of attorney on behalf of the taxpayer.)

(Signature)

(Title, if applicable)

(Also type or print your name below if signing for a taxpayer

who is not an individual.)

(Date)

(Signature)

(Title, if applicable)

(Date)

*y ou must authorize an organization, firm, or partnership to receive confidential information, but your representative must be an

individual who must complete part II.

Power Of Attorney And Declaration Of Representative

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