Tn Department Of Revenue Form – Fill Out and Use This PDF

TENNESSEE DEPARTMENT OF REVENUE

POWER OF ATTORNEY

1. Taxpayer Information (Taxpayer must sign and date this form on line 6.)

Taxpayer name and address

Account number(s)

Daytime telephone number

()

hereby appoints the following representative as attorney-in-fact:

2.Representative (Representative must sign and date this form on page 2, Part II.)

Name and address

Telephone No. (			)
Fax No. (	)

to represent the taxpayer before the Tennessee Department of Revenue for the following tax matters:

3.Tax Matters

	Type of Tax (Sales and Use, Franchise, Excise, etc.)	Year(s) or Period(s)

4.ActsAuthorized. --The representative is authorized to receive and inspect confidential tax information and to perform any and all acts that I can perform with respect to the tax matters described in line 3, for example, the authority to sign any agreements, consents, or other documents. The authority does not include the power to receive refund checks.

5.NoticesandCommunication.--Noticesandotherwrittencommunicationswillbesenttothefirstrepresentativelistedinline2.

6.Signature of Taxpayer.- If signed by a corporate officer, partner, guardian, tax matters partner/person, executor, receiver, administrator,ortrusteeonbefalfofthetaxpayer,I certifythatIhavetheauthoritytoexecutethisformonbehalfofthetaxpayer.

Signature

Date

Title (if applicable)

Print Name

RV-F0103801

Under penalties of perjury, I declare that:

..I am authorized to represent the taxpayer(s) identified in Part 1 for the tax matter(s) specified there; and I am one of the following:

a.Attorney or Certified PublicAccountant

b.Officer or full-time employee taxpayer organization

c.Other

If this declaration of representative is not signed and dated, the power of attorney will be returned.