Fillable Printable Form 2484 - Alabama Power of Attorney and Declaration of Representative

Form 2484 - Alabama Power of Attorney and Declaration of Representative

ALABAMADEPARTMENTOFREVENUE

Power of Attorney

andDeclaration of Representative

NAME AND ADDRESS

To represent the taxpayer(s) before the Alabama Department of Revenue for the following tax matters:

TAXPAYER NAME(S) AND ADDRESS (Please Type or Print)SOCIAL SECURITY NUMBER(S)EMPLOYER IDENTIFICATION NUMBER

DAYTIME TELEPHONE NUMBER

()

Hereby appoint(s) the following representative(s) as attorney(s)-in-fact:

FORM

2848A

(REV. 10/05)

NOTE:If you have questions concerning the completion of this form, please refer to the instructions for Federal

Form 2848 (revised March 2004). Alabama Form 2848A is very similar to the federal form.

PART I – POWER OF ATTORNEY

1TAXPAYER INFORMATION

2REPRESENTATIVE(S) (Please Type or Print)

3TAX MATTERS

4ACTS AUTHORIZED

The representative(s) are authorized 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 on line 3, (for example, the authority to sign any agreements, consents, or

other documents). The authority does not include the power to receive refund checks or the power to sign certain returns.

5RECEIPT OF REFUND CHECKS

If you want to authorize a representative named on line 2 to receive, BUT NOT TO ENDORSE OR CASH, refund checks,

initial here ___________ and list the name of that representative below.

TELEPHONE NUMBER()

FAX NUMBER()

TELEPHONE NUMBER()

FAX NUMBER()

TELEPHONE NUMBER()

FAX NUMBER()

TYPE OF TAX (Individual, Corporate, Sales, etc.)TAX FORM NUMBER (40, 20C, 41, 65, etc.)YEAR(S) or PERIOD(S)

LIST ANY SPECIFIC ADDITIONS OR DELETIONS TO THE ACTS OTHERWISE AUTHORIZED IN THIS POWER OF ATTORNEY:

NAME OF REPRESENTATIVE TO RECEIVE REFUND CHECK(S)

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FORM 2848A

DESIGNATION – INSERT

ABOVE LETTER (a-h)

JURISDICTION (State) or

ENROLLMENT CARD NO.

SIGNATUREDATE

FORM 2848A (REV. 10/05)PAGE 2

6NOTICES AND COMMUNICATIONS

Notices and other written communications will be sent to the first representative listed in Part I, section 2.

aIf you want the second representative listed to receive such notices and communications, check this box..................

អ

bIf you do not want any notices or communications sent to your representative, check this box............................

អ

cIf you want any notices and communications sent to both you and your representative, check this box....................

អ

7RETENTION / REVOCATION OF PRIOR POWER(S) OF ATTORNEY

The filing of this power of attorney automatically revokes all earlier power(s) of attorney on file with the Alabama

Department of Revenue for the sametax matters and years or periods covered by this document. If you do not want

to revoke a prior power of attorney, check here............................................................................

អ

YOUMUSTATTACHA COPYOFANYPOWEROFATTORNEYYOUWANTTOREMAININEFFECT.

8SIGNATURE OF TAXPAYER(S)

If a tax matter concerns a joint return, bothhusband and wife must sign if joint representation is requested, otherwise, see federal

instructions. If signed by a corporate officer, partner, guardian, tax matters partner, 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 this power of attorney is not signed, it will be returned.

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SIGNATUREDATETITLE (If Applicable)

PRINT NAME

SIGNATUREDATETITLE (If Applicable)

PRINT NAME

PART II – DECLARATION OF REPRESENTATIVE

Under penalties of perjury, I declare that:

•I am not currently under suspension or disbarment from practice before the Internal Revenue Service;

•I am aware of regulations contained in Treasury Department Circular No. 230 (31 CFR, Part 10), as amended, concerning the

practice of attorneys, certified public accountants, enrolled agents, enrolled actuaries, and others;

•I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there; and

•I am one of the following:

aAttorney – a member in good standing of the bar of the highest court of the jurisdiction shown below.

bCertified Public Accountant – duly qualified to practice as a certified public accountant in the jurisdiction shown below.

cEnrolled Agent – enrolled as an agent under the requirements of Treasury Department Circular No. 230.

dOfficer – a bona fide officer of the taxpayer’s organization.

eFull-Time Employee – a full-time employee of the taxpayer.

fFamily Member – a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister).

gEnrolled Actuary – enrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the

authority to practice before the Service is limited by section 10.3(d)(1) of Treasury Department Circular No. 230).

hUnenrolled Return Preparer – an unenrolled return preparer under section 10.7(c)(1)(viii) of Treasury Department Circular No.

230.

If this declaration of representative is not signed and dated, the power of attorney will be returned.

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