Form Poa-1 - Power Of Attorney
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1INDIANA DEPARTMENT OF REVENUE
POA - 1
POWER OF ATTORNEY
Rev. 10/99
Taxpayer(s) Name(s)
Indiana Taxpayer Identification Number
Address
Federal Identification Number
City
Social Security Number
State
Zip
Spouse's Social Security Number
Hereby appoint(s) the following :
(If Firm or Corp, give Appointee(s) Name)
Firm/Corp/Individual Name
Firm/Corp/Individual FID, PTIN, or SSN Number
Street Address
Daytime Telephone Number
City
State
Zip + 4
Appointee
Firm/Corp/Individual Name
Firm/Corp/Individual FID, PTIN, or SSN Number
Street Address
Daytime Telephone Number
City
State
Zip + 4
Appointee
Firm/Corp/Individual Name
Firm/Corp/Individual FID, PTIN, or SSN Number
Street Address
Daytime Telephone Number
City
State
Zip + 4
Appointee
Firm/Corp/Individual Name
Firm/Corp/Individual FID, PTIN, or SSN Number
Street Address
Daytime Telephone Number
City
State
Zip + 4
Appointee
Type of Tax
Year(s)/Period(s)
Said attorney(s) - in - fact shall (subject to revocation) have authority to receive confidential information and full power to perform on behalf of the
undersigned all acts incidental to such representation:
If signed by the Corporation Officer, Partners,or Fiduciary on behalf of the taxpayer, I certify that I have the authority to execute this Power of Attorney
on behalf of the taxpayer:
Signature
Spouse
Title
Date
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Parent category: Financial