Form 2848-Me - Power Of Attorney And Declaration Of Representative Template Page 2
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2If the power of attorney is granted to a person other than an attorney, certifi ed public accountant or enrolled agent, the
taxpayer(s) signature must be witnessed or notarized below. (The representative(s) must complete Part II.)
The person(s) signing as or for the taxpayer(s): (Check and complete one.)
is/are known to, and signed in the presence of, the two disinterested witnesses whose signatures
appear here:
___________________________________________
_______________________________
(Signature of Witness)
(Date)
___________________________________________
_______________________________
(Signature of Witness)
(Date)
appeared this day before a notary public and acknowledged this power of attorney as a voluntary
act and deed.
Witness: ________________________________
________________
NOTARIAL SEAL
(Signature of Notary)
(Date)
PART II
My commission expires: _____________
PART II
Declaration of Representative
Under penalties of perjury, I declare that I am: (Circle one)
1. A member in good standing of the bar of the highest court of the jurisdiction shown below;
2. Duly qualifi ed to practice as a certifi ed public accountant in the jurisdiction shown below;
3. An enrolled agent enrolled under U. S. Department of Treasury Circular 230;
4. A bona fi de offi cer of the taxpayer’s organization;
5. A full-time employee of the taxpayer;
6. A member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);
7. A fi duciary for the taxpayer;
8. Other (Explain) ______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Designation
Jurisdiction
Signature
Date
(insert appropriate
(state, etc.)
number from list above)
IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED,
THE POWER OF ATTORNEY WILL BE RETURNED.
Revised: April, 2008
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