cam 2848 Power of Attorney |_ousio.ssis-0rs0 tho sana 205) and Declaration of Representative = Pita Rove >» Go to winnirs.gov/Form2648 for instructions and the latest information, Power of Attorney Caution: A separate Fon 2648 must be completed for each taxpayer. Form 2848 will not be honored for any purpose otter than representation before the IS. Taxpayer informatio. Taxcaver must sign and dats this frm on page 2, Tne 7. Taxpayer name anc address “Taxpayor wonieation number) FIRST MIDDLE LAST SSN-XX-KXXX 1234 YOUR ADDRESS ST. ‘Dayilme talephone number | Pan aumber OF approani) CITY / TOWN, ST 12345 (xxx) _XXK-XKKX Fereby appoints the folowing representative) as altomayia iv fark 2_Representative(s) must sign and date this form on page 2, Pat ‘Name and ecoress AF No. First Middle last eer c/o 1234 Your Address Street ae see RES or 1234 Post Office address Tetapnone No, GE) _ REAR Checkitte Bosak conn Sl adios sad comiruicatione OY | Checkitneur acess CT” aephane ie I) Fho. Namo ane accross CAF No Conn PTW es Tetepnane No es Fano Check if to be sent copies of notices and communications [] ‘Cheok itnew: Address [| Telephone No. [} Fax No. C) Name an econ CAF No nl PTW Es Telephone No Fax No (Noe: soncs notices and communications o only no representatives] Check new: Addai Name and access CAF No. PTW Telephone No. Fax No ~ (Note: IRS sends notices anc communications to only two representatives: Checkit naw: Addiess|-] Telephone No.) Fax No. C) {o ropresont the taxpayer before the Intomal Revenue Sorvice and perform the folowing acts: 3. Acts authorized (you are required to complete line 3). Except forthe acts described inne So, | authorize my reprosertatves) to recaive and Inspect my confidential tax Formation and to perform acts | can perforn wth respect to the tax matters dancribed below. For exampla, my representatives) shall havo the authority to sign any acreements, consents, or similar Cocumants (606 instuctons for Ine Ba for authorizing @ representative to ign return), Description of Mater (income, Employment, Payroll, Excise, Fatale, Git, ‘gee rte Sane PA an Cuironay Se | qqug.tn raoel arsine) |" Gecranaton) Appointment of Fiduciary 56 2021 COMPANY NAME Acct. # XXXXXXXXXx 1041, 1099-O0ID 2021 @— Specific uso nat recorded on tho Centralized Authorization Fs (CAR, I the power cf alumey & fora peal ws wal eoa'deo om GAR, check this box. See Line 4. Specitic Lise Not Recorded on CAF in the instructions -o ‘a Additional cts authorized. n accion othe ais std on ne @ above, authorize my vores fo peor tne ellowng acts eee instructions for line 6a for more information): [Z] Acogss my IRS records via an intermediate Service Provider; (il Authorize cisotosure to third parties; [2] supsttute or add represeniative(s); [Xl Sign a return: Request tax transcripts for tax years 2016-2021 with form 4506-77 File withholding certificates for tax year 2021\with form W-4. Se Wotheracts authorized: filing tax documents for YOUR COUNTY COURT account # xxxxxuxxux, filing tax documents for EXAMPLE UTILITY 0, account # xxxxxxxxxx For Privacy Act and Paperwork Reduction AcI Notice, see the instructions. ‘Gat No, 96 Form BB4B ov 12027)Farm 2848 ow 1-200), Page 2 'b Specific acts not authorized. My representatives (are) not authorized to endorse or otherwise negotiate any check (neluding erecting or ‘accepting payment by any mears, electronic or otherwise, into an account owed or controlled by the representatlvet} or any fm or ethar tentty with whom the representave(s) is (ae) associated) ssusd by the goverment in respect ef faderal tax ably List any other specific doltions to the cts otherwise autherize in this power of atorney (ee instructions fr fine BD} {6 Rotontion/revecation of prior power(s) of attomay. The iing of this power of allernay auiomatcally rovekos all earlor powers) of attomey on fle with the Intemal Revenue Service for the same matters and years or petioc's covered by this form, If you do Not want to revoke prior power of attomay, check here ce > YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT. 7 Taxpayer declaration and signature. If tax matter concems year in which a joint retumn was flea, each spouse must fle a separate power of attorney even if they are apnointing the seme representatives. If signad by a corporate cificer, partner, quardian, tax matters partner pparthershio representative (or designated individual if applicable), executor, recoive, administrator, tustes, or individual olor than the taxpayer, |cerify | hava the legal authority fo execute ths for on behalf the taxpayer > IF NOT COMPLETED, SIGNED. *ND DATED, THE IRS WILL RETURN THIS POWER OF ATTORNEY TO THE TAXPAYER. BY: Fine Midtdte TODAY'S DATE Attorney in Fact an ‘Signature ie ‘Baie ‘Tis epplieabiey First Middle Last FIRST MIDDLE LAST — Printrame — Print name of taxpayer from line 1 if other than individual Declaration of Representative ‘Under penates of pey, by my sgnatre below | clare that: am not curently suspend! or elsbaed trom practice or heli for practice, before te rterral Revenue Service; +m subject to regulon in irulr 250 (81 OF, Subtie A, Par 0), 28 amended, governing practice befoce the intemal Revenve Sev; ‘am authorized to represent the taxpayer ented in Par for he matters) spect there; and ‘am on9 ofthe folowing: 4 Atorney—a member in good stand ofthe bar ofthe highest cour ofthe jursdition shown below bb Cortiod Pubic Accountant—a holder ofan active conse to practice asa certiod public accountant in tho jsdicton shown below. € Ervaliod Agent—anrliod as an agent bythe IAS por tho requirements of Circular 230, Officer—a bona fide ocr of tho txoayer ganization. © Ful-Time Employoo—a fulltime employoo ofthe taxoaver. 1 Farily Mombe-—a mombor of to taxpayer's irmoclt family spouse, parent, cil, randpeent, grandhil,stop-prent.sop-chid, bother, o iste @ Errolled Actuary—erroled as an ecusry by the Joint Board forthe Eroiment of Acturies urdor 28 U.S.C, 1282 the authority to practice betore {he IS i tec by section 10 Sie of Cer 230} hy Unervalee Return Preparer—Authorty te practice before the IS slimited. An uneraled return preparer may represent, onde the preparer) ‘reparedl an signed he retura a clam fr relune or prepare if tere sro sgaturs apace on se frm); 2 ws eile to sh the return oe lam for relune @) has a vale PTIN nd} possestes the requted Annual Fg Season Program Racor of Competions) See Specel Rules ‘and Requirements for Unenrolled Return Preparers inthe Instructions for adltional information. i Qualiving Student or Law Graduate—recsives pacrisson to ranrsant taxpayers befor the IS by vitus of hiner status as a, business, lascourting student, o aw graduate working in LITC or STCP, Sas inen.ctions for Pat I far ational information and raqument. F Erroled Retiement Pian Agent—erroled as aretiremont plan agent under tho requirements of Cicular 230 (he authority to practice betee the Interal Revenue Seve imiod by section 0.3. > IF THIS DECLARATION OF REPRESENTATIVE IS NOT COMPLETED, SIGNED, AND DATED, THE IRS WILL RETURN THE POWER OF ATTORNEY. REPRESENTATIVES MUST SIGN IN THE ORDER LISTED IN PART |, LINE 2. Noto: Fer designations enter yur tte, pasion, a relatonahip tothe taipyerin the “onan uration” alum, Licensing juriscietion earn oar, ese, conten, Tastabow | , 2209" aH”) eestor or omer Sora bate ‘etter (ann). fapplieable) number (ff applicable} Fam 2B4B ov 1.2027),