How to Write
1 – Save This Form As A PDF File
This form is available as a PDF file (a popular file type for legal forms). To begin, select the link on the right. If you have a form-friendly browser or the appropriate software you may enter the requested information directly onscreen. If not, you may print out this form then fill it out manually.
2 – Supply the Principal Taxpayer’s Information
Locate the first item, “Taxpayer Information,” then enter the Full Name and Address of the Taxpayer providing authorization for the Agent to act with Principal Power at the Taxpayer’s disposal. Note: this should be the Complete Address of the Principal Taxpayer (i.e. Building Number/Street/Apt Number, Street, City, State, and Zip Code).
The next column will require the Principal Taxpayer’s Social Security Number(s). The Principal Taxpayer’s Social Security Number should be entered next to the word “Primary.” If the Principal Taxpayer includes a husband or wife, then report his or her Social Security Number next to the word “Spouse.”
If the Principal Taxpayer has an applicable Sales Tax Permit Number, this may be reported in the box below the reported Social Security Numbers.
If the Principal has an EIN, this should be reported in the box labeled “Employer Identification Number”
Report the Telephone Number where the Principal may be reached during business hours under the words “Daytime Telephone Number.”
3 – Present the Principal Taxpayer’s Representative Agent(s)
Locate the second section, titled “Representative(s),” this section will require information regarding the individual who the Principal Taxpayer has elected to represent him or her with the Department of Finance and Administration. There is enough room to name two Representatives (only one is required). If there are two Representatives, make sure their information is reported in their respective rows.
In the first box, record the Full Name and Complete Address of the individual the Principal Taxpayer has elected Make sure this information is reported accurately and corresponds to this individual’s credentials.
In the second column of this section, report the Telephone Number and Fax Number where the elected Representative may be reliably reached.
4 – Define Concerned Tax Matters
In the third section, “Tax Matters,” there will be a table with two columns. In the left column, report the subjects in which the Representative may exert Principal Powers on behalf of the Taxpayer. Then in the second column, report the Year or Time Period pertaining to the defined subject area in which the Representative’s Principal Authority should be honored.
Locate the statement introduced with the phrase “List any specific additions…” Using the blank lines provided below this statement, the Principal should define any additional circumstances, conditions, extensions, provisions, restrictions, terms, etc. that should be applied to the authority being granted to the Representative. This section may be left blank.
5 – Authorizing Signature
In the sixth item, titled “Signature of Taxpayer(s),” each Taxpayer granting authority to the Representative Agent named on this form must Sign his or her Name on the Signature line. This must be followed with the Date of Signature, and the Principal’s Title on the next two spaces. There is enough room for two Principal Taxpayer’s to provide these items.