Rev184 Form – Fill Out and Use This PDF

Taxpayer’s name

Spouse’s name (if a joint return)

Social Security or Minnesota tax ID number (or federal ID number)

Spouse’s Social Security number (if a joint return)

Print or Type

Street address

City

Expiration date

(If a date is not provided, this power of attorney is valid until revoked.)

State

Zip code

Month Day Year

Check one (see instructions):

Original—your irst power of attorney authorizing this appointee

Amend—changes an existing power of attorney for this appointee

Cancel/Revoke—cancels a previously iled power of attorney

Power of Attorney

Sign Here Election

(Rev. 9/11)

I appoint the following as attorney-in-fact to represent me before the Minnesota Department of Revenue. I understand it is my responsibility to keep my appointee informed of my tax matters and of any matters relating to my nontax debts that have been referred to the department for collection. I also understand that the department does not send copies of all correspondence to my appointee. (For exception, see “Elec- tion” below.)

Name of person (appointee) given power of attorney	Name of irm (if applicable)
Street address	City	State	Zip code
Phone number	FAX number

The appointee is authorized to provide and receive private and nonpublic information concerning my state taxes and my nontax debts re- ferred to the department for collection, and:

I grant full authority to the appointee. The appointee is authorized to perform any and all acts I can perform with respect to my tax mat- ters and to my nontax debts referred to the Department of Revenue for collection.

Check this box if the appointee is not authorized to sign tax returns.

I grant limited authority for speciic tax types, periods and/or duties. Check only the boxes that apply. By checking the boxes, the ap- pointee will be authorized to perform acts on your behalf with respect to only the indicated tax matters. If a speciic year or period is not

indicated for a selected tax type, the powers granted will apply to all years and/or periods, both past and future:

Check this box if the appointee is not authorized to sign the return(s) for the tax matters indicated below.

Tax type	Year(s) or period(s)	Tax type	Year(s) or period(s)
Individual income tax		Sales and use tax
Property tax refund		Withholding tax
Partnership tax		S corporation tax
MinnesotaCare taxes		Corporation franchise
Fiduciary income tax		Nontax debt matters
Other (please specify):
Comments:

Election for appointee to receive all correspondence, including refunds, from the department. If you make this election, you will no longer receive anything—including refunds, legal notices and correspondence—from the department, and your appointee will receive it all on your behalf. To make this election, complete and attach Form REV184a to this form.

The power of attorney is not valid until it is signed and dated.

Taxpayer’s signature or signature of corporate oficer, partner or iduciary	Print name (and title, if applicable)	Date	Phone
Spouse’s signature (if joint)	Print spouse’s name (if joint)	Date	Phone

Submit a signed copy of this Power of Attorney to the Department of Revenue using one of the following methods:

•Attach in a secure email to MNDOR.POA@state.mn.us;

•FAX to 651-556-5210; OR

•Mail to Minnesota Revenue, Mail Station 4123, St. Paul, MN 55146-4123

Purpose

You must complete, sign and return this form if you want to grant power of attor- ney to an attorney, accountant, agent, tax return preparer or any other person as an attorney-in-fact to perform acts on your behalf and to discuss with the department your private tax matters and matters related to your nontax debts that have been referred to the department for collection. A power of attorney is a legal document authorizing someone to act as your representative.

You may use this form for any matters af- fecting any tax administered by the Depart- ment of Revenue. his includes both the audit and collection processes. You may also use this form for any matters afecting any nontax debt that has been referred to the department for collection.

his power of attorney will remain in efect until the expiration date, if any, or until you revoke it, whichever is earlier.

he department will accept copies of this form, including those from a FAX machine.

Original, Amend or

Cancel/Revoke

Check one box to indicate your intent for iling this form.

Original—Check this box if this power of attorney is new and does not amend or replace any existing power of attorney on ile with the department.

Amend—Check this box if you have an existing power of attorney on ile with the department for the appointee and you want to make changes. When you complete this form, briely describe the changes in the blank space provided for comments.

Cancel/Revoke—Check this box if you want to revoke an existing power of attor- ney for the appointee that is on ile with the department. (Note: It is not necessary for you to ile this form to revoke a previously iled power of attorney. If you prefer, you may revoke an earlier power of attorney by writing to the department.)

If you choose not to cancel/revoke a previ- ous power of attorney, you are considered to have multiple representatives.

Expiration Date

If you want the power of attorney to end on a speciic date, ill in the month, day and year.

If a date is not provided, the power of attor- ney will remain valid until it is revoked.

Appointee

Fill in the name, address, phone and FAX number of the person and/or irm, organi- zation or partnership you are appointing to represent you before the department. If you ill in the name of a person and the name of a irm, you are appointing both that person and anyone else who is with that irm to represent you. If the person you are naming leaves the irm, that person is still consid- ered to be your appointee, in addition to the irm you are naming. At any time ater you ile this form, if you decide that either the person or the irm no longer represents you, submit another Form REV184 that amends, cancels or revokes the original form.

Granting Powers

Check one box to grant full or limited authority to the power of attorney. If the appointee is not authorized to sign your tax returns, check the appropriate box.

If you want to grant limited authority, you must indicate the speciic tax types, periods and/or duties you want the appointee to perform. If a speciic year or period is not indicated for a selected tax type, the powers granted will apply to all years and/or peri- ods, both past and future.

If your tax situation does not it into a tax type or period (for example, a speciic ad- ministrative appeal, audit or collection mat- ter), describe it in the blank space provided for comments.

If you do not want to grant authority to the appointee to sign your return, you must check the box.

Nontax Debt Matters

If the department is attempting to collect nontax debts referred to it by other public entities, the appointee is authorized to per- form any and all acts that you can perform with respect to all these nontax debts, unless you specify otherwise. To grant limited authority regarding nontax debt matters, be sure to check the appropriate box on the front of this form.

Election for Appointee to Receive All Correspondence

Please note that as a general rule, the department does not routinely send docu- ments to the designated appointee. Your appointee might receive certain tax debt documents, but not all of them. herefore, it is your responsibility to keep your appointee informed of your tax matters.

To elect everything to be sent to your power of attorney rather than you State law allows you to make an election in writing to have the department send any and all refunds, legal notices, correspondence, and tax information directly to the appointee rather than you. his election is efective only for the authority you have granted to your appointee. If you make this election, you will no longer receive anything from the department and your appointee will receive it all on your behalf, including any refunds.

To make this election, complete and attach Form REV184a, Election to Receive All Cor- respondence from the Department of Revenue, to this form.

Your Signature

he power of attorney is not valid until it is signed and dated.

Your signature at the bottom of this form authorizes the individual you designate (your representative or “attorney-in-fact”) to perform any act you can perform with the department. his authority includes signing consents to a change in tax liability, consents to extend the time for assessing or collecting tax, closing agreements and compromises.

If you are granting authority for a joint re- turn, both signatures are required. However, only one signature is needed if you are grant- ing powers for disclosure purposes only.

If you want to exclude granting authority to perform any of these, or other speciic acts, describe those exclusions in the blank space provided for comments.

Use of Information

he information collected on this form may be private or nonpublic data and, if so, cannot be disclosed to the public or other agencies. It will only be used for tax admin- istration purposes or collection of nontax debts. If you do not provide all the requested information, your Form REV184 may not be processed.

Questions?

Website: www.taxes.state.mn.us

Email: Individual.IncomeTax@state.mn.us

Phone: 651-296-3781 or 1-800-652-9094 (TTY: Call 711 for Minnesota Relay)