Rev 677 Le Form – Fill Out and Use This PDF

REV-677 LE (05-14)

POWER OF ATTORNEY AND

DECLARATION OF

REPRESENTATIVE

GENERAL INSTRUCTIONS:

This form provides limited authority for department representatives to speak about confidential tax matters with designated third parties. Such authority is limited to the tax period, tax type and the specific issue/purpose identified herein.

While tax practitionersare encouraged to maintain appropriate declarations of authority to handle clients' tax matterswithintheir own records, tax practitioners should not submit unsolicited REV-677 forms to the department en masse or asa matter of routine. Such forms will be disregarded.

A REV-677 form should only be submitted to an individual within the department upon an agent's request for such authorization.

If a department representative has requested a REV-677 form to authorize discussion of confidential tax matters with a third party, please return the form to the department representative as requested.

PART I	Power of Attorney	NOTE: An organization, firm or partnership may not be designated as a taxpayer’s representative.
The following taxpayer
Taxpayer Name				Identifying Number
Address				City				State		ZIP
hereby appoints
Appointee Name(s)				Telephone Number		Preparer Tax Identification Number (PTIN)
Address				City				State		ZIP

as attorney-in-fact to represent the taxpayer before any office of the PA Department of Revenue for the following tax matter(s). Specify the type(s) of tax, tax year(s) or period(s), tax return/report at issue and the specific purpose for which authorization to discuss confidential tax matters with a third-party is sought.

Type(s) of tax	Tax Year(s) or Period(s)	Tax Return/Form	Purpose for Authorization

The attorney-in-fact is authorized, subject to revocation, to receive confidential information and perform any and all acts the principal can perform with respect to the above-specified tax matters, excluding the power to receive refund checks and the power to sign the return, unless specifically granted below.

Initial here

to grant the power to receive – but not to endorse or cash – refund checksfor the above-referenced tax matters to

the appointee named above.

Only if this form is being submitted to the department in response to an audit, provide an address below to which copies may be sent of notices

and other written communications addressed to the taxpayer in proceedings involving the above-specified tax matters.

Appointee Name(s)

Telephone Number

State

Address

City

ZIP

This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the PA Department of Revenue for the

same matters and years or periods covered by this power of attorney, except the following:

Granter Name

Date

Refer to attached copies of

earlier powers and authorizations

State

Address

City

ZIP

Signature of or for taxpayer

If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer, such party certifies he/she has the authority to execute this power of attorney on behalf of the taxpayer.

If the power of attorney is granted to a person other than an attorney, certified public accountant or enrolled agent, the taxpayer's signature must be witnessed or notarized below.

The person signing as or for the taxpayer (check and complete one):

is known to and signed in the presence of the two disinterested witnesses whose signatures appear here:

		(Signature of Witness)					(Date)
		(Signature of Witness)					(Date)
appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.
Witness							NOTARIAL SEAL
		(Signature ofNotary)		(Date)

PART II Declaration of Representative

I declare that I am one of the following:

1a member in good standing of the bar of the highest court of the jurisdiction indicated below;

2duly qualified to practice as a certified public accountant in the jurisdiction indicated below;

3a bona fide officer of the taxpayer organization;

4a full-time employee of the taxpayer;

5a member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);

6a fiduciary for the taxpayer; and/or

7 Other (specify);

and that Iam authorized to represent the taxpayer identified in Part I for the tax matters specified therein.