Fillable Printable Power of Attorney Form with Instructions - Indiana
Fillable Printable Power of Attorney Form with Instructions - Indiana
Power of Attorney Form with Instructions - Indiana
1)
Indiana Taxpayer Identifi cation Number
Employer Identifi cation Number
Social Security Number
Spouse's Social Security Number
Taxpayer(s) Name(s)
D\B\A Name(s)
Address
City
State Zip Code
Telephone #
( )
INDIANA DEPARTMENT OF REVENUE
POWER OFATTORNEY
(Instructions on Back)
POA - 1
Rev. 3/07
SF 49357
2)
3)
4)
5)
6)
Individual Representative Name Additional Individual Representative Name
AddressAddress
City State Zip CodeCity State Zip Code
Telephone #
( ) Telephone # ( )
Firm/Corp. Name (If applicable)If Firm or Corp. list Representative(s) Name
a)
Addressb)
City State Zip Codec)
Telephone #
( )
d)
Type of Tax
(Income, Withholding, Sales, etc.)
Tax Form Number
(IT-40, WH-3, ST-103, etc.)
Year(s) / Period(s)
7)
Hereby appoint(s) the following :
I acknowledge that the designated representative has the authority to receive confidential 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 officer, partner or fiduciary acting on behalf of the taxpayer, I certify that I have authority to execute this Power of Attorney on
behalf of the taxpayer.
Signature Date
Title Telephone # ( )
Instructions for Indiana Form POA-l
Casual conversations with a taxpayer's representative, who does not have a Power of Attorney on file, are permitted.
However, neither tax return information nor taxpayer-specifi c information will be disclosed to the representative unless a
properly executed Power of Attorney has been filed with the Indiana Department of Revenue.
Pursuant to 45 IAC 15-3-4, a properly executed Power of Attorney must contain the following information.
1. The taxpayer's name, D\B\A name, address and telephone number.
2. The Indiana taxpayer's identifi cation number (TID). The TID number is assigned by the Indiana Department of
Revenue; each entity has its own TID number. The employer identifi cation number (EIN) is a number provided by the
Internal Revenue Service. Individual taxpayers should use their Social Security Numbers unless they have been issued a
TID number.
3. Enter the name, address and telephone number of your individual representative(s). Only individuals may be named as
representatives. If you want to add one additional individual representative, indicate so in the space provided. If you want
to add more than one additional individual representative, indicate so in the space provided and attach a list of additional
representatives to the form.
4. If your representative works for a firm or corporation, enter the name, address and phone number of the company.
Enter the individual name of your representative(s). Only individuals may be named as representatives. If you want to add
more than four individual representatives for a firm or corporation, indicate so in the space provided and attach a list of
additional representatives to the form.
5. The Power of Attorney form must contain the specifi c type of tax, tax form number and the tax years for which the
individual representative has been appointed.
6. Include as an attachment any restrictions or limitations which the taxpayer has placed on the representative while act-
ing as the taxpayer's representative.
7. The Power of Attorney form must be signed by the taxpayer or an individual authorized to execute the Power of At-
torney on behalf of the taxpayer.
After the taxpayer executes a Power of Attorney, the Department of Revenue will communicate primarily with the
taxpayer's representative.
The Indiana Department of Revenue accepts faxed or electronic copies of original Power of Attorney Forms. If a
copy is provided, the person forwarding the copy certifi es, under penalties for perjury, that the copy is a true, accurate and
complete copy of the original document.
This Power of Attorney can only be revoked by written and signed notice.
To submit the form you may either fax to: (317) 615-2736 or mail to:
Indiana Department of Revenue
P.O. Box 7230
Indianapolis, IN 46207-7230
