EFTA00800091.pdf

DR-835 III 1111111111111111111111111111111 Florida Department of Revenue POWER OF ATTORNEY R. 10/11 TC Rule 12.6 0015 and Declaration of Representative ROOM Acimniseaove Code [Melee lent See Instructions for additional information PART I - POWER OF ATTORNEY Section 1. Taxpayer Information. Taxpayer(s) must sign and date this form on Page 2. Pal I I. Section 8. ri.,,,o).ct r.dret,:s1 ono aoi,est(esi f &loran D noes). (SSN'. Celle. Mel ' 'or de Tax Registration Numberkl Illimnoss Part No.. Saks Tax No. R f nut No. etc I Contact person TkephOne number ( ) f ax number ( ) The Taxpayer(s) hereby appoint(s) the following representative(s) as attorney(s)-in-fact: Section 2. Representative(s). Each representative must be listed Individually, and must sign and date this form on Page 2. Pan II. Nome and °cares, orcit.ce rote e"i'm Il applcatke Telephone numb°. ) fax number ( ) rank address: Cell phone number ( ) Name and address (include name of rem I 04,VICAel0) Telephone number ) Fax numtei Ernst ackeess. Cell phone number ) Name and acicuess linClude name of km N °optical:0W Telephone rumba ( ) Fax number ) address Cell phone number ) To represent the taxpayer(s) before the Florida Department of Revenue in the following tax matters: Section 3. Tax Matters. Do not complete this section if completing Section 4. iype 'ex (Corporate. Sales. Reemploymeni. CO/Melly UnemplOyMent etc.) YearN / Tax Matteis) [Tax Audits. Precasts. Refunds. etc.) Section 4. To Appoint a Reemployment Tax (formerly Unemployment Tax) Agent Only. Do not complete Sections 3 and 6 if completing Section 4. By completing this section. an employer (taxpayer) appoints a representative to act as its Florida reemployment tax agent before the Florida Department of Revenue on a continuing basis and to receive confidential information with respect to mailings, filings, and other tax matters related to the Florida reemployment assistance program law. All other sections of this form (except Sections 3 and 6) must also be completed. Do not complete Section 4 unless you wish to appoint a reemployment tax agent on a continuing basis. Agent name Agent number 51206 rah F rm nacre Fecletal No ('ellficeo) Address oi atietent tram above) reiephoro nvntor ( ) Mail Type: See Instructions for explanations. Check one box only. 0 1 (Primary) 0 2 (Reporting) 0 3 (Rate) 0 4 (Claim) Section 5. Acts Authorized The representative(s) 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 in Section 3 and Section 4 (for example, the authority to sign any agreements, consents, or other documents). Except as otherwise provided, the authority specifically includes the power to execute waivers of restrictions on assessment or collection of deficiencies in tax. to execute consents extending the statutory period for assessment or claims for refund of taxes, and to execute closing agreements under section 213.21. Florida Statutes. This authority does not include the power to endorse or cash warrants, or the power to sign certain returns. If you want to authorize a representative named in Section 2 to receive (but not to endorse or cash) refund wartants, write the name of the representative on this line and check the box 0 List any specific limitations or deletions to the acts otherwise authorized in the Power of Attorney. EFTA00800091  iuII II Florida Tax Registration Number: DR-835 R. 10/11 Page 2 Taxpayer Name(s): Federal Identification Number: Taxpayer(s) must complete Page 1 of this Power of Attorney or it will not be processed. Section 6. Notices and Communication. Do not complete Section 6 if completing Section 4. • Notices and other written communications will be sent to the first representative listed in Part I, Section 2. unless the taxpayer selects one of the options below. Receipt by either the representative or the taxpayer will be considered receipt by both. a. If you want notices and communications sent to both you and your representative, check this box 0 b. If you want notices or communications sent to you and not your representative, check this box 0 0 Certain computer-generated notices and other written communications cannot be issued in duplicate due to current system constraints. Therefore, we will send these communications to only the taxpayer at his or her tax registration address. Section 7. Retention / Nonrevocation of Prior Power(s) of Attorney. The filing of this Power of Attorney will not revoke earlier Power(s) of Attorney on file with the Florida Department of Revenue. even for the same tax matters and years or periods covered by this document. If you want to revoke a prior Power of Attorney. check this box 0 0 You must attach a copy of any Power of Attorney you wish to revoke. Section 8. Signature of Taxpayer(s). If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested. If signed by a corporate officer. partner, member/managing member, guardian. tax matters partner/person, executor, receiver, administrator, trustee, or fiduciary on behalf of the taxpayer. I declare under penalties of perjury that I have the authority to execute this form on behalf of the taxpayer. Under penalties of perjury, I (we) declare that I (we) have read the foregoing document, and the facts stated in it are true. If this Power of Attorney is not signed and dated. it will be returned. Signature Date Tine (rapplicabte) Print Name Signatarc Date 100 (II applitablel Print Name PART II - DECLARATION OF REPRESENTATIVE Under penalties of perjury, I declare that: • 1 am familiar with the mandatory standards of conduct governing representation before the Department of Revenue. including Rules 12-6.006 and 28.106.107 of the Florida Administrative Code. as amended. • I am familiar with the law and facts related to this matter and am qualified to represent the taxpayer(s) in this matter. • lam authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified therein, and to receive and inspect confidential taxpayer information. • 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 pursuant to the requirements of Treasury Department Circular Number 230. d. Former Department of Revenue Employee. As a representative. I cannot accept representation in a matter upon which I had direct involvement while I was a public employee. e. Reemployment Tax Agent authorized in Section 4 of this form. f. Other Qualified Representative • I have read the foregoing Declaration of Representative and the facts stated in it are true. Desgnaton - !men Jurisdiconn (State: and Letter tram Above (HI Enrooment Card No. Of any) Signature Date EFTA00800092  DR-835 R. 10/11 Page 3 POWER OF ATTORNEY INSTRUCTIONS Purpose of this form Section 2 - Representative(s) A Power of Attorney (Form DR-835) signed by the taxpayer and the Enter the individual name. turn name (il applicable). address. telephone representative is required by the Florida Department of Revenue in number(s), and fax number of each individual appointed as attorney-in- order for the taxpayer's representative to perform certain acts on behalf fact and representative. If the representatives have the same address. of the taxpayer and to receive and inspect confidential tax information. simply write "same" in the appropriate box. If you wish to appoint more You and your representative must complete. sign, and return Form than three representatives. you should attach a letter to Form DR-835 DR-835 if you want to grant Power of Attorney to an attorney, certified listing those additional individuals. public accountant. enrolled agent, former Department employee, Section 3 • Tax Matters reemployment tax agent. or any other qualified individual. A Power of Enter the type(s) of tax this Power of Attorney authorization applies to Attorney is a legal document authorizing someone other than yourself and the years or periods for which the Power of Attorney is granted. to act as your representative. The word •All" is not specific enough. If your tax situation does not fit You may use this form for any matters affecting any tax administered into a tax type or period (for example, a specific administrative appeal. by the Department of Revenue. This includes both the audit and audit, or collection matter), describe it in the blank space provided for collection processes. A Power of Attorney will remain in effect until you "Tax Matters: The Power of Attorney can be limited to specific revoke it. If you provide more than one Power of Attorney with respect reporting period(s) that can be stated in year(s), quarter(s). month(s). to a tax and tax period, the Department employee handling your case etc., or can be granted for an indefinite period. You must indicate the will address notices and correspondence relative to that issue to the tax types, periods, and/or matters for which you are authorizing first person fisted on the latest Power of Attorney. representation by your attorney-in-fact. A Power of Attorney Form is generally not required, if the representative Examples: is. or is accompanied by: a trustee. a receiver. an administrator, an executor of an estate, a corporate officer, or an authorized employee of Sales and Use Tax First and second quarter 20O8 the taxpayer. Corporate Income Tax 7/1/07 - 6/30/08 Communications Services Tax 2006 thru 2008 Photocopies and fax copies of Form DR-835 are usually acceptable. E- mail transmissions or other types of Powers of Attorney are not Insurance Premium Tax 1/1/06 12/31/08 acceptable. Co ies of Form D - r r 'ly available by visiting our Technical Assistance Advisement Request dated 8/6/08 Internet site ). Claim for Refund 3/7/07 How to Complete Form DR-835, Power of Attorney Section 4 - To Appoint a Reemployment Tax Agent PART I POWER OF ATTORNEY Complete this section only if you wish to appoint an agent for Section 1 - Taxpayer Information reemployment taxes on a continuing basis. You should not complete • For individuals and sole proprietorships: Enter your name. Section 3 or Section 6, but you must complete the remaining sections address. social security number, and telephone number(s) in the of Form DR-835. spaces provided. Enter your federal employer identification number Enter the agent's name. It must be the same name as found in Section (FEIN), if you have one. If a joint return is involved. and you and your 2. Enter the firm name and address. You do not need to complete the spouse are designating the same attomey(S)-in-fact, also enter your address line if you reported that information in Section 2. spouse's name and social security number, and your spouses address if different from yours. 1. Enter the agent number. The agent number is a seven-digit number assigned by the Department of Revenue. • For a corporation, limited liability company, or partnership: Enter the name, business address. FEIN. a contact person familiar 2. Enter the federal employer identification number. The FEIN is a with this matter, and telephone number(s). nine-digit number assigned to the agent by the Internal Revenue Service. • For a trust: Enter the name, title, address, and telephone number(s) of the fiduciary, and name and FEIN of the trust. 3. Select the mail type. • For an estate: Enter the name, title. address. and telephone Primary Mall. If you select primary mail, the agent will receive all numberfs) of the decedent's personal representative, and the name documents from the Department of Revenue related to this and identification number of the estate. The identification number reemployment tax account, and will be authorized to receive for an estate includes both the FEIN if the estate has one and the confidential information and discuss matters related to the tax and decedent's social security number. wage report, benefit information, claims, and the employer's rate. • For any other entity: Enter the name, busineSS address, FEIN, and Reporting Mail. If you select reporting mail, the agent will receive the telephone number(s), as well as the name of a contact person Employer's Quarterly Report (Form RT-6). certification, and familiar with this matter. correspondence related to reporting. The agent will be authorized to receive confidential information and discuss the tax and wage report. • Identification Number: The Department may have assigned you a certification, and correspondence with the Department. Florida tax registration number such as a sales tax number, a reemployment tax account number. Or a business partner number. Rate Mall. If you select rate mail, the agent will receive tax rate notices These numbers further assist the Department in identifying your and correspondence related to the rate and will be authorized to particular tax matter, and you should enter them in the appropriate receive confidential information and discuss the employer's rate notices box. If you do not provide this information. the Department may not and rate with the Department. be able to process the Power of Attorney. Claims Mail. If you select claims mail, the agent will receive the notice of benefits paid. and will be authorized to receive confidential information and discuss matters related to benefits. Note: Duplicate copies of certain computer-generated notices and other written communications cannot be issued due to current system constraints and therefore. these communications will be sent only to the representative. EFTA00800093  DR-835 R. 10/11 Page 4 Note: If you wish to appoint a representative to act on your behalf in a in this matter and will comply with the mandatory standards of conduct specific and non-continuing reemployment tax matter, you should governing representation before the Department of Revenue. The complete Section 3 and Section G and not Section 4. For example. if representative(s) must also declare. under penalties of perjury. that he you hire a representative to assist you with a single matter, such as a or she has been authorized to represent the taxpayer(s) in this matter reemployment tax audit or contesting the payment of a claim, and wish and authorized by the taxpayer(s) to receive confidential taxpayer that representative to handle just that one matter, you should not information. complete Section 4 to authorize that representation. Instead, you should fill out Section 3 and specify the exact matter the representative The representative(s) you name must sign and date this declaration and is handling. enter the designation (i.e., items a-f) under which he or she is authorized to represent you before the Department of Revenue. Section 5 - Acts Authorized Your signature on the back of the Power of Attorney authorizes the a. Attorney - Enter the two-letter abbreviation for the state (for individual(s) you designate (your representative or 'attorney-in-fact") to example "FL" for Florida) in which admitted to practice, along perform any act you can perform with respect to your tax matters. with your bar number. except that your representative may not sign certain returns for you nor b. Certified Public Accountant - Enter the two-letter abbreviation may your representative negotiate or cash your refund warrant. This for the state (for example -FL' for Florida) in which licensed to authority includes signing consents to a change in tax liability, consents practice. to extend the time for assessing or collecting tax. closing agreements. and compromises. You may authorize your representative to receive. c. Enrolled Agent - Enter the enrollment card number issued by the but not negotiate or cash. your refund warrant by checking the box in Internal Revenue Service. Section 5 and writing the name of the representative on the line below. d. Former Department of Revenue Employee - Former employees If you wish to limit the authority of your representative other than in the may not accept representation in matters in which they were manner previously described, you must describe those limits on the directly involved. and in certain cases, on any matter for a period lines provided in Section 5. of two years following termination of employment. If a former Section 6 - Mailing of Notices and Communications Department of Revenue employee is also an attorney or CPA, If you do not check a box, the Department will send notices and other then the additional designation. jurisdiction, and enrollment card written communications to the first representative listed in Section 2. should also be entered. unless you select another option. If you wish to have no documents e. Reemployment Tax Agent - A person(s) appointed under Section sent to your representative, or documents sent to both you and your 4 of the Power of Attorney to handle reemployment tax matters representative. you should check the appropriate box in Section 6. on a continuing basis. A separate Power of Attorney form must Check the second box if you wish to have notices and other written be completed in order for a reemployment tax agent to handle a communications sent to you and not to your representative. In certain specific and non-continuing matter such as a protest of a instances, the Department can only send documents to the taxpayer. reemployment tax rate. Therefore. the taxpayer has the responsibility of keeping the representative informed of tax matters. f. Other Qualified Representative - An individual may represent a taxpayer before the Department of Revenue if training and Note: Taxpayers completing Section 4 (To Appoint a Reemployment experience qualifies that person to handle a specific matter. Tax Agent Only) should not complete Section 6. See Section 4 of these instructions for information regarding notices and communications sent Rule 28-106.107. Florida Administrative Code. sets out mandatary to a reemployment tax agent. standards of conduct for all qualified representatives. A representative shall not: Section 7 - Retention/Nonrevocation of Prior Power(s) of Attorney The most recent Power of Attorney will take precedence over. but will (a) Engage in conduct involving dishonesty. fraud, deceit, or not revoke. prior Powers of Attorney. II you wish to revoke a prior misrepresentation. Power of Attorney, you must check the box on the form and attach a (b) Engage in conduct that is prejudicial to the administration of copy of the old Power of Attorney. justice. Section 8 - Signature of Taxpayer(s) (c) Handle a matter that the representative knows or should know The Power of Attorney is not valid until signed and dated by the that he or she is not competent to handle. taxpayer. The individual signing the Power of Attorney is representing, under penalties of perjury, that he or she is the taxpayer or authorized (d) Handle a legal or factual matter without adequate preparation. to execute the Power of Attorney on behalf of the taxpayer. 'Social security numbers (SSNs) are used by the Florida • For a corporation. trust, estate, or any other entity: A corporate Department of Revenue as unique identifiers for the administration of officer or person having authority to bind the entity must sign. Florida's taxes. SSNs obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, • For partnerships: All partners must sign unless one partner is and not subject to disclosure as public records. Collection of your authorized to act In the name of the partnership. e and federal law. Visit our Internet site S • ' • For a sole proprietorship: The owner of the sole proprietorship at and select "Privacy Notice' for more must sign. information regarding the state and federal law governing the collection, use, or release of SSNs. including authorized exceptions. • For a joint return: Both husband and wife must sign if the representative represents both. If the representative only Where to Mail Form DR-81S represents one spouse. then only that spouse should sign. If Form DR-835 is for a specific matter, mail or fax it to the office or employee handling the specific matter. You may send it with the PART II - DECLARATION OF REPRESENTATIVE document to which it relates. Any party who appears before the Department of Revenue has the right. at his or her own expense, to be represented by counsel or by a If Form DR•835 is for a reemployment tax matter and the taxpayer has qualified representative. The representative(S) you name must declare. pleted Section 4, mail it to the Florida Department of Revenue. under penalties of perjury. that he or she is qualified to represent you M. Box 6510, Tallahassee FL 32314-6510, or fax it to 850-488-5997. EFTA00800094