Form Hsmv 96440 – Fill Out and Use This PDF

Division of Motorist Services

Bureau of Commercial Vehicle

and Driver Services

POWER OF ATTORNEY (POA)

AND DECLARATION BY AUTHORIZED AGENT

PART 1 – POWER OF ATTORNEY

Section 2. Authorized Agent (Representative)

Section 3. Acts Authorized by the Registrant/Licensee

A photocopy of the Registrant/Licensee’s Driver License must be filed with this FORM 96440

I authorize the representative described in Section 2 to receive and inspect confidential information and transact on my behalf with respect to both my International Registration Plan (IRP) and my International Fuel Tax Agreement (IFTA) accounts, which I have listed in Section 1. This authority specifically includes the power to fill out and submit IRP/IFTA transactional forms, receive IRP and IFTA credentials; and represent the Registrant/Licensee in audit and/or collection matters. This authority does not include the power to endorse or cash warrants; execute consents for compromise and closing agreements that financially bind the Registrant/Licensee; or to sign applications requiring attestation from the Registrant/Licensee. I also understand that filing this POA revokes all earlier POA(s) on file with the Department. Under penalties of perjury, I affirm that I am authorized to execute this Power of Attorney and I declare that the information in the foregoing Sections 1 and 2 are true and correct.

Signature:_________________________________________________________________ Title:__________________________________________ Date:_______________

Partner in the Carrier Company (MUST HAVE SUNBIZ REGISTRATION AND AUTHORITY TO ACT ON BEHALF OF PARTNERSHIP)

TO BE COMPLETED BY A NOTARY:

The above has been sworn to (or affirmed) and subscribed before me this __________ day of ________________________, 20__________, by:

HSMV 96440 (REV. 12/2017)

Page 2

Name of Registrant/Licensee: _______________________________________________FEIN:________________________________

PART II – DECLARATION OF AUTHORIZED AGENT (REPRESENTATIVE)

I understand that the Power of Attorney (POA) on the forgoing page of this Form 96440 is not valid until it is signed and dated by the Registrant/Licensee in the presence of a notary; the Declaration of Authorized Agent (Representative) on the present page is signed and dated by me; and this completed (two-page) Form 96440 has been filed with the Department of Highway Safety and Motor Vehicles, Division of Motorist Services, Bureau of Commercial Vehicle and Driver Services.

Under penalties of perjury, I declare that:

•With respect to the forgoing POA related to the International Registration Plan(IRP) and the International Fuel Tax Agreement (IFTA), I am the individual (or officer of the motor carrier service provider company) authorized to represent the Registrant/Licensee identified in Section 1, in the matters specified in Section 3.

•If applicable, I have attached (or have previously filed with the Bureau of Commercial Vehicle and Driver Services) a complete list of the printed names, respective signatures, and copies of the driver licenses of all authorized agents employed by my company to represent IRP Registrants and IFTA Licensees.

•I am (and if applicable, the authorized agents of my company are) familiar with the plan requirements of the IRP and IFTA, as well as the related provisions of Chapters 207 and 320 Florida Statutes.

•I am (and if applicable, the authorized agents of my company are) familiar with the business procedures of the Bureau of Commercial Vehicle and Driver Services as they relate to IRP and IFTA transactions, and I am (we are) willing and able to follow these procedures on behalf of the Registrant/Licensee.

•The Authorized Agent information provided in Section 2 of the forgoing document is true and correct.

Name of the Service Provider Company (if applicable)

HSMV 96440 (REV. 12/2017)