Fillable Printable Financial Power of Attorney - Minnesota

Financial Power of Attorney - Minnesota

Primary appointee: Name of person given power of attorney

Street address City State ZIP code

Phone number Fax number Email address

I appoint the above person, and anyone included on the attachment, as attorney-in-fact to represent me before the Minnesota Department of Revenue. It is

my responsibility for determining if the person I appoint as my Power of Attorney (POA) is eligible to practice before the department under Minnesota Rules

8052.0300 and to keep my appointee informed of my tax and my nontax debt matters referred to the department for collection. I understand the department

does not send copies of all correspondence to my appointee. (For exception, see “Optional Elections” below.)

I grant full authority to the appointee(s). The appointee(s) is authorized to perform all acts I can perform with my tax and nontax debt matters

referred to the Department of Revenue for collection.

Check this box if the appointee(s) is not authorized to sign tax returns.

I grant limited authority for specifi c tax types, periods and/or duties (check only the boxes that apply). By checking the boxes, the appointee(s)

will be authorized to act on my behalf only for the indicated tax matters. If I do not indicate a specifi c year or period for a selected tax type, I am

granting authority for all years or periods.

Check this box if the appointee(s) is not authorized to sign the return(s) for the tax matters indicated below.

Tax type Years or periods Tax type Years or periods

Individual Income Tax Sales and Use Tax

Property Tax Refund Withholding Tax

Nontax Debts MinnesotaCare Taxes

Business Income Taxes Other (describe below)

(Corporate Franchise Tax, Fiduciary Income Tax, Partnership Tax,

S Corporation Tax, and Unrelated Business Income Tax)

Check any that apply (see instructions):

Authorize primary appointee to receive all correspondence, including refunds, from the department.

I elect to have the Minnesota Department of Revenue send the primary appointee all refunds, legal notices, and correspondence about the tax

and nontax debt matters specifi ed in this document. By making this election, I understand that I will no longer receive anything—including refunds

and legal notices—from the department and my primary appointee will receive it on my behalf.

Authorize appointee to communicate by email.

I authorize the Minnesota Department of Revenue to communicate by email with my appointee(s). I understand private tax data about me will be

sent over the Internet. I accept the risk my data may be accessed by someone other than the intended recipient. I agree the Minnesota Depart-

ment of Revenue is not liable for any damages I may have as a result of interception (have the appointee sign on the line below).

Appointee signature (for email authorization) Date

Taxpayer’s name (person or business) Social Security or Minnesota tax ID number (or federal ID number)

Spouse’s name (if a joint income tax return) Spouse’s Social Security number (if a joint income tax return)

Street address City State ZIP code

Taxpayer

Information

Add—appoints a new power of attor-

ney authorizing the appointee(s)

Check only one (see instructions):

Power of Attorney

REV184

Power of Attorney

(Rev. 12/14)

This power of attorney and elections are not valid until signed and dated by the taxpayer.

Taxpayer’s signature (or corporate offi cer, partner or fi duciary) Print name (and title, if applicable) Date Phone

Spouse’s signature (if joint income tax return) Print spouse’s name Date Phone

Send a signed copy of this form to the department:

In a secure email to [email protected], by fax to 651-556-5210, or by mail to Minnesota Revenue, Mail Station 4123, St. Paul, MN 55146-4123

Signature and

Expiration

Optional

Elections

Change—changes an existing power

of attorney for the appointee(s)

Remove—ends the power of attorney for

the appointee(s)

Expiration Date

(If a date is not provided, this power of attorney and optional elections are valid until removed.)

Month Day Year

Authority Granted

If removing an appointee, skip the next two sections, then sign and date the form.