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Indiana Department of Revenue
POWER OF ATTORNEY
1. Taxpayer Information
Taxpayer(s) Name(s)
DBA Name(s) (if applicable)
Address ☐New Address
CityStateZip Code
Telephone Number
2. Identication Numbers
Indiana Taxpayer Identification Number (10 digits) or Employer Identification Number
—
Social Security Number Spouse’s Social Security Number
Hereby appoint(s) the following:
3. Representative Information
Individual Representative Name
Additional Individual Representative Name
AddressAddress
CityStateZip CodeCityStateZip Code
Telephone NumberEmailTelephone NumberEmail
Additional Individual Representative NameAdditional Individual Representative Name