Form

2848

Power of Attorney

OMB No. 1545-0150

(Rev. December 1997)

and Declaration of Representative

For IRS Use Only

Received by:

Name

Telephone

Function

Department of the Treasury Internal Revenue Service

See the separate instructions.

Date

/

/

Taxpayer name(s) and address

hereby appoint(s) the following representative(s) as attorney(s)-in-fact:

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

		

to represent the taxpayer(s) before the Internal Revenue Service for the following tax matters:

3 Tax matters

4

Specific use not recorded on Centralized Authorization File (CAF). If the power of attorney is for a specific use not recorded

on CAF, check this box. (See instruction for Line 4—Specific uses not recorded on CAF.)

	

5 Acts authorized. The representatives are authorized to receive and inspect confidential tax information and to perform any

and all acts that I (we) can perform with respect to the tax matters described on Iine 3, for example, the authority to sign any agreements, consents, or other documents. The authority does not include the power to receive refund checks (see line 6 below), the power to substitute another representative unless specifically added below, or the power to sign certain returns (see instruction for Line 5—Acts authorized).

List any specific additions or deletions to the acts otherwise authorized in this power of attorney:

Note: In general, an unenrolled preparer of tax returns cannot sign any document for a taxpayer. See Revenue Procedure 81-38,

printed as Pub. 470, for more information.

Note: The tax matters partner of a partnership is not permitted to authorize representatives to perform certain acts. See the

instructions for more information.

6 Receipt of refund checks. If you want to authorize a representative named on Iine 2 to receive, BUT NOT TO ENDORSE
and list the name of that representative below.

OR CASH, refund checks, initial here

Name of representative to receive refund check(s)

For Paperwork Reduction and Privacy Act Notice, see the separate instructions.

Cat. No. 11980J

Form 2848 (Rev. 12-97)

Daytime telephone number

Plan number (if applicable)

Name and address

CAF No.

Telephone No.

Fax No.

Telephone No.

Check if new: Address

Name and address

CAF No.

Telephone No.

Fax No.

Telephone No.

Check if new: Address

Name and address

CAF No.

Telephone No.

Fax No.

Telephone No.

Check if new: Address

Part I
Power of Attorney (Please type or print.)	
1	Taxpayer information (Taxpayer(s) must sign and date this form on page 2, line 9.)		

Social security number(s)	Employer identification number	

Type of Tax (Income, Employment, Excise, etc.)	Tax Form Number (1040, 941, 720, etc.)	Year(s) or Period(s)	

			

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Form 2848 (Rev. 12-97)

Page 2

7 Notices and communications. Original notices and other written communications will be sent to you and a copy to the first representative listed on line 2 unless you check one or more of the boxes below.

a If you want the first representative listed on line 2 to receive the original, and yourself a copy, of such notices or communications, check this box

	

b If you also want the second representative listed to receive a copy of such notices and communications, check this

box

	

cIf you do not want any notices or communications sent to your representative(s), check this box

	

8

Retention/revocation of prior power(s) of attorney. The filing of this power of attorney automatically revokes all earlier power(s) of attorney on file with the Internal Revenue Service for the same tax matters and years or periods covered by

this document. If you do not want to revoke a prior power of attorney, check here

YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.

9

Signature of taxpayer(s). If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested, otherwise, see the instructions. If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.

IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.

Signature

Date

Title (if applicable)

Print Name

Signature

Date

Title (if applicable)

Print Name

Part II

Declaration of Representative

Under penalties of perjury, I declare that:

•	I am not currently under suspension or disbarment from practice before the Internal Revenue Service;

•	I am aware of regulations contained in Treasury Department Circular No. 230 (31 CFR, Part 10), as amended, concerning

the practice of attorneys, certified public accountants, enrolled agents, enrolled actuaries, and others;
•	I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there; and

•	I am one of the following:

a Attorney— a member in good standing of the bar of the highest court of the jurisdiction shown below.
b Certified Public Accountant—duly qualified to practice as a certified public accountant in the jurisdiction shown below. c Enrolled Agent—enrolled as an agent under the requirements of Treasury Department Circular No. 230.
d	Officer— a bona fide officer of the taxpayer’s organization.

e Full-Time Employee— a full-time employee of the taxpayer.

f Family Member— a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister).

g	Enrolled Actuary—enrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the

authority to practice before the Service is limited by section 1 0.3(d)(1) of Treasury Department Circular No. 230).

h	Unenrolled Return Preparer— an unenrolled return preparer under section 10.7(c)(viii) of Treasury Department Circular

No. 230.
IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE RETURNED.

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Designation—Insert above letter (a–h)	Jurisdiction (state) or Enrollment Card No.	Signature	Date