Fillable Printable Power of Attorney Example Form - Indiana

Power of Attorney Example Form - Indiana

Indiana Department of Revenue

POWER OF ATTORNEY

1. Taxpayer Information

Taxpayer(s) Name(s)

DBA Name(s) (if applicable)

Address ☐ New Address?

City State Zip Code

Telephone Number

2. Identication Numbers



Indiana Taxpayer Identification Number (10 digits) or Employer Identification Number

—

Social Security Number Spouse’s Social Security Number

Hereby appoint(s) the following:

3. Representative Information

Individual Representative Name

Additional Individual Representative Name

Address Address

City State Zip Code City State Zip Code

Telephone Number Email Telephone Number Email

Additional Individual Representative Name Additional Individual Representative Name

Address Address

City State Zip Code City State Zip Code

Telephone Number Email Telephone Number Email

4. Firm/Vendor Information

Firm/Vendor Name (if applicable)

Address

City State Zip Code

Telephone Number Email

POA - 1

State Form 49357

(R6 / 11-14)

If rm or vendor, list representative(s) name, telephone number and email.

Representative(s) Name Telephone Number Email

5. General Authorization

☐ I authorize the listed representative(s), in addition to anything otherwise authorized on this form, to represent me regarding any

matters with the Indiana Department of Revenue regardless of tax years or income periods. I understand that this authority will expire 5

years from the date this POA is signed or a written and signed notice is filed revoking this authorization.

6. Tax Type(s) (Not applicable if box is checked in question 5 above)

Type of Tax Year(s)/Period(s)

(Income, Withholding, Sales, etc.) ☐ Current Year ☐ Specify

_______________________________________ ___________________________________

I acknowledge that the designated representative has the authority to receive condential information and full power to perform on behalf of

the taxpayer in tax matters related to this Power of Attorney. This authority does not include the power to receive refund checks.

I acknowledge that actions taken by the designated representative are binding, even if the representative is not an attorney. Proceedings

cannot later be declared legally defective because the representative was not an attorney.

If I am a corporate ofcer, partner, or duciary acting on behalf of the taxpayer, I certify that I have authority to execute this Power of Attorney

on behalf of the taxpayer.

7. Authorizing Signature

Signature _______________________________________________ Date _______________________________

Printed Name ____________________________________________ Title _______________________________

Telephone Number ________________________________________ Email ______________________________



Required elds - if not complete, this form will be returned to sender.

Instructions for Indiana Form POA-1

Casual conversations with a taxpayer’s representative who does not have a Power of Attorney on le are permitted.

However, the Indiana Department of Revenue will not disclose tax return information or taxpayer-specic information to

the representative unless a properly executed Power of Attorney has been led with the department. In lieu of a Power

of Attorney, you can authorize the department to discuss your tax return information with someone else by lling out the

Personal Representative Portion on your individual tax return.

Pursuant to 45 IAC 15-3-4, a properly executed Power of Attorney must contain the following information:

1. The taxpayer’s name, DBA name (if applicable), address (Please check the box if this is a new address), and tele-

phone number.

2. The Indiana taxpayer’s identication (10-digit TID) number. The department assigns TID numbers, and each entity

has its own TID number. The Internal Revenue Service provides the employer identication number (EIN). Individual

taxpayers should use their Social Security numbers unless they have been issued a TID number.

3. The name, address, and telephone number of your individual representative(s).Only individuals can be named as

representatives. If you want to add one individual representative, enter one in the spaces provided. If you want to add

more representatives, enter them in the spaces provided.

4. If your representative works for a consulting rm or vendor, enter the company’s name, address, telephone number,

and email address. Enter the individual name of your representative(s). Only individuals can be named as represen-

tatives. If you want to add more than four individual representatives for a rm or vendor, enter them in the spaces

provided.

5. Check this box if you want to authorize your representative to represent you regarding all tax matters, regardless of

the tax year or income period involved.

6. The Power of Attorney form can contain the specic type of tax, or the option ALL. By choosing the option ALL, you

will be allowed access to ALL tax types appropriate to the taxpayer. The tax years must be specic.

7. The taxpayer’s signature or the signature of an individual authorized to execute the Power of Attorney on the taxpay-

er’s behalf.

NOTE: Include as an enclosure any restrictions or limitations the taxpayer has placed on the representative while acting

as the taxpayer’s representative.

After the taxpayer executes a Power of Attorney, the department will communicate primarily with the taxpayer’s represen-

tative.

The department accepts faxed copies of original Power of Attorney forms. If a copy is provided, the person forward-

ing the copy certies, under penalties for perjury, that the copy is a true, accurate, and complete copy of the original docu-

ment.

Do not send POA-1 via email. This is not a secure means of transmittal.

The department will not accept a Power of Attorney form that has been altered unless it has the initials of the taxpayer (or

an individual authorized to execute the Power of Attorney on the taxpayer’s behalf) beside the alteration(s).

This Power of Attorney is effective for 5 years from the date the form is signed. After the expiration of 5 years, a new Pow-

er of Attorney form must be completed if the taxpayer wishes to permit the department to communicate with the taxpayer’s

representative.

This Power of Attorney can be revoked prior to expiration only by written and signed notice. A subsequent Power of Attor-

ney alone will NOT revoke a prior Power of Attorney.

Required elds – if not complete, this form will be returned to sender.

Submit the form using these methods:

• Fax: (317) 615-2605

• Mail: Indiana Department of Revenue

PO Box 7230

Indianapolis, IN 46207-7230