1
Taxpayer information. Taxpayer must sign and date this form on page 2, line 7.
Taxpayer name and address
hereby appoints the following representative(s) as attorney(s)-in-fact:
2
Representative(s) must sign and date this form on page 2, Part II.
to represent the taxpayer before the Internal Revenue Service and perform the following acts:
3
Acts authorized (you are required to complete line 3).
Except for the acts described in line 5b, I authorize my representative(s) to receive and
inspect my confidential tax information and to perform acts I can perform with respect to
the
tax
matters
described below. For example, my
representative(s) shall have the authority to sign any agreements, consents, or similar
documents
(see
instructions for line 5a for authorizing a
representative to sign a return).
Description of Matter (Income, Employment, Payroll, Excise, Estate,
Gift,
Whistleblower, Practitioner Discipline, PLR, FOIA, Civil Penalty, Sec.
4980H
Shared
Responsibility
Payment, etc.) (see instructions)
Tax Form Number
(1040, 941, 720, etc.) (if applicable)
Year(s) or Period(s) (if applicable)
(see
instructions)
Under penalties of perjury, by my signature below I declare that:
• I am not currently suspended or disbarred from practice, or ineligible for practice,
before
the
Internal
Revenue Service;
• I am subject to regulations in Circular 230 (31 CFR, Subtitle A, Part 10), as amended,
governing
practice
before the Internal Revenue Service;
• I am authorized to represent the taxpayer identified in Part I for the matter(s)
specified
there;
and
• I am one of the following:
a Attorney—a member in good standing of the
bar
of
the
highest court of the jurisdiction shown below.
b Certified Public Accountant—a holder of
an
active
license
to practice as a certified public accountant in the jurisdiction shown below.
c Enrolled Agent—enrolled as an agent by
the
IRS
per the
requirements of Circular 230.
d Officer—a bona fide officer of the
taxpayer
organization.
e Full-Time Employee—a full-time employee
of
the
taxpayer.
f Family Member—a member of the taxpayer's
immediate family
(spouse, parent, child, grandparent, grandchild, step-parent, step-child, brother, or
sister).
g Enrolled 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 IRS is limited by section 10.3(d) of Circular 230).
h Unenrolled Return Preparer—Authority to
practice
before
the IRS is limited. An unenrolled return preparer may represent, provided the preparer
(1)
prepared and signed the return or claim for refund (or
prepared
if
there is no
signature space on the form); (2) was eligible to sign the return
or
claim for
refund; (3) has a valid PTIN; and (4) possesses the required Annual Filing Season Program
Record
of
Completion(s). See Special Rules
and Requirements for
Unenrolled
Return
Preparers in the instructions for additional information.
k Qualifying Student or Law
Graduate—receives
permission to
represent taxpayers before the IRS by virtue of his/her status as a law, business,
or
accounting student, or law graduate working in a LITC or STCP.
See
instructions
for Part II for additional information and requirements.
r Enrolled Retirement Plan Agent—enrolled
as a
retirement
plan agent under the requirements of Circular 230 (the authority to practice before
the
Internal Revenue Service is limited by section 10.3(e)).
▶ IF THIS DECLARATION OF REPRESENTATIVE IS NOT COMPLETED, SIGNED, AND DATED, THE IRS WILL RETURN
THE
POWER OF ATTORNEY. REPRESENTATIVES MUST SIGN IN THE ORDER LISTED IN PART I, LINE 2.
Note: For designations d–f, enter your title, position, or relationship to the taxpayer
in
the
"Licensing
jurisdiction" column.
