Form 3520 - Ca Power Of Attorney - General Information - 2015 Page 5
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52015
CA38
CAPOA
Form 3520 - CA Power of Attorney - General Information
(714) 284-4802 ▪ (844) 327-6740 ▪ Fax (714) 254-7210 ▪ Website:
Except for tax years, enter data only if the information differs from Federal Form POA {95E}
1100 E. Orangethorpe Ave., Suite 100, Anaheim, CA 92801
(T/S) [1]
Taxpayer/Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Separate forms must be submitted for TP & SP)
[2]
New address if different . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address if different:
[3]
Address
. . . . . . . . . . . . . . .
(35)
/ State / Zip . . . . . . . . . [4]
[5]
[6]
City
(20)
[§ 7] Business Entity information
Business Name
State
Zip Code
(40)
Address
City
#
New
FEIN
* SOS Number
Telephone
Fax
* SOS Number must be
10 or 12 digits
Authorize all matters for four years (or enter tax calendar years below). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [8]
Tax Calendar years or income periods covered by the POA (75)
[9]
Fiscal years and short-period income years
[§10]
Additional privileges:
[11]
Add another representative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[12]
Delete a representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[13]
Receive, but not endorse, refund check. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other authorized acts . . . . [§ 14]
[§ 15]
Deletions to authorized acts
[16]
Incapacitating disease or injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[17]
Continous absence from United State for at least 60 days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[19]
Retain (Do not revoke) prior power of attorney. . . . . . . . . . . . . . . . . . . . . .
No
(1 = Yes, Retain / Do not revoke , 2 =
)
Nontax issues:
[20]
Vehicle registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
[21]
Court-ordered debt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax years or income periods covered to receive confidential information only:
Calendar years. . . . . . . . . . [§ 22]
Fiscal years and short-period income years [§ 23]
Representative Information
Enter data ONLY if the information differs from the federal Form POA {95E}.
[24]
Representative #1 name
(35)
[25]
Representative Address
(35)
[26]
[27]
[28]
City
/ State / Zip Code . . . .
(20)
[29]
CAF number . . . . . . . . . . . . . .
[30]
PTIN . . . . . . . . . . . . . . . . . . . . .
[31]
Telephone number . . . . . . . . .
[32]
Fax number . . . . . . . . . . . . . . .
[33]
[34]
New address . . . . . . . . . . . .
New telephone . . . . . . . . . . .
[35]
New email address . . . . . . .
[36]
Email address . . . . . . . . . . . . .
[37]
Representative #2 name
(35)
[38]
Representative Address
(35)
[39]
[40]
[41]
City
/ State / Zip Code . . . .
(20)
[42]
CAF number . . . . . . . . . . . . . .
[43]
PTIN . . . . . . . . . . . . . . . . . . . . .
[44]
Telephone number . . . . . . . . .
[45]
Fax number . . . . . . . . . . . . . . .
[46]
[47]
New email address . . . . . . . . [48]
New address . . . . . . . . . . . .
New telephone . . . . . . . . . . .
[55]
Email address . . . . . . . . . . . . .
Paper Filing Exceptions
Enter all that apply. If no exceptions are met then POA declaration must be filed online at ftb.ca.gov via MyFTB account.
[56]
[59]
Located in a declared disaster area . .
Documented physical/mental impairment . . . . . . .
Non-professional representative . . . . . [57]
[60]
First-time filer for the State of California . . . . . . . .
[58]
[61]
Do not have a PTIN, EFIN, etc. . . . . .
Active duty military member in combat zone . . . . .
Other explanation. . . . . . . . . . . [62]
5ICAPOA
02
02/05/16
ExacTax, Inc.
CA38
INDIVIDUAL
5
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