Power Of Attorney Form - State Of Arkansas Department Of Finance And Administration
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1
2State of Arkansas
Date of
Revocation
Department of Finance and Administration
Power of Attorney
__________
1 Taxpayer Information
Social Security Number(s)
Employer Identification
Taxpayer name(s) and address (Please type or print)
Number
Primary
Spouse
Sales tax permit number
Daytime Telephone Number
hereby appoint(s) the following representative(s) as attorney(s)-in-fact:
2 Representative(s)
Name and address (Please type or print)
Telephone Number
Fax Number
Name and address
Telephone Number
Fax Number
to represent the taxpayer(s) before the Arkansas Department of Finance and Administration for the following tax matters:
3
Tax Matters
Type of Tax (Sales, Use, Income, etc.)
Year(s) or Period(s)
4 Acts Authorized
The representatives are authorized, subject to revocation by the taxpayer, to receive and inspect confidential tax
information and to perform any and all acts that I (we) can perform with respect to the tax matters described in line 3,
including the authority to sign any agreements, consents, waivers or other documents.
The authority does not include the power to receive refund checks, the power to substitute another representative, the
power to sign returns, or the power to execute a request for disclosure of tax returns or return information to a third party.
List any specific additions or deletions to the acts otherwise authorized in this power of attorney:
5 Computer generated notices will continue to be sent to taxpayer as required by law (see instructions).
6
Signature of Taxpayer(s)
If signed by a corporate officer, partner, guardian, executor, receiver, administrator, or trustee on behalf of the taxpayer, I
certify that I have the authority to execute this form on behalf of the taxpayer. If a tax matter concerns a joint return,
both husband and wife must sign if joint representation is requested.
If not signed and dated, this power of attorney will be returned.
Signature
Date
Title
Signature
Date
Title
(Revised 08/05)
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