Form Par 101 - Virginia Power Of Attorney And Declaration Of Representative
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4DEPARTMENT OF TAXATION
FORM PAR 101
P.O. BOX 1115
VIRGINIA POWER OF ATTORNEY AND
RICHMOND, VA 23218-1115
Individual Fax: 804-254-6113
DECLARATION OF REPRESENTATIVE
Business Fax: 804-254-6111
LINE 1 Taxpayer Information - Taxpayer(s) must furnish the information requested and sign and date this form.
Taxpayer Name(s) and Address
Your Social Security Number
Spouse's Social Security
Number
Federal Employer ID Number
Daytime Telephone Number
(if applicable)
(
)
E-mail Address
LINE 2 Representative(s) - The representative(s) must sign and date this form. The two representatives listed here will receive written
copies of correspondence as discussed in the Instructions. Only individuals may be named as representatives. See the instructions for
additional information.
Name and Address
Virginia Authorized
A -
Agent Number
(
)
Phone Number
(
)
Fax Number
E-Mail Address
Check here if you do not want this representative to receive
copies of correspondence for the tax matter specified below
on Line 3.
Name and Address
Virginia Authorized
A -
Agent Number
(
)
Phone Number
(
)
Fax Number
E-Mail Address
Check here if you do not want this representative to receive
copies of correspondence for the tax matter specified below
on Line 3.
The representative(s) above are authorized to represent the taxpayer(s) before the Virginia Department of Taxation for the
following tax matters:
LINE 3 Tax Matters - Enter type of tax and year(s) or period(s) or date of death if Estate Tax. Do not use a general reference such as
“All taxes”, “All years,” or “All periods.”
Beginning Period
Ending Period
Virginia Tax Account Number
Tax Type
(MM/YYYY format)
(MM/YYYY format)
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