Form 21-002 "Power of Attorney and Declaration of Representation" - Mississippi

What Is Form 21-002?

This is a legal form that was released by the Mississippi Department of Revenue - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Mississippi Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 21-002 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Revenue.

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Download Form 21-002 "Power of Attorney and Declaration of Representation" - Mississippi

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POWER OF ATTORNEY
AND
DECLARATION OF REPRESENTATION
Form 21-002-13
PART I POWER OF ATTORNEY
For DOR Use Only
Taxpayer(s) Information
Taxpayer Name(s) and Mailing Address
Taxpayer Social Security Number
Received by:
Name
__________________________
Spouse Social Security Number
Phone
_________________________
Federal ID Number (FEIN)
____________________
Date
Hereby appoint(s) the following representative(s):
Representative Information
Name and Mailing Address
(
)
Phone Number
_________________________________________________
(
)
FAX Number
_________________________________________________
Name and Mailing Address
(
)
Phone Number
________________________________________________
(
)
FAX Number
_________________________________________________
Name and Mailing Address
(
)
Phone Number
_________________________________________________
(
)
FAX Number
_________________________________________________
To represent the taxpayer(s) before the Mississippi Department of Revenue in:
Tax Matter(s)
Tax Type (Income, Franchise, Sales, Insurance Premium, etc.)
Account Number
Tax Period(s)
Acts Authorized
I (we) as the taxpayer(s) give authorization to the representative(s) to receive and inspect confidential tax information and
to perform any and all acts that the taxpayer(s) can perform with respect to the matters concerning the taxes and
accounts described under Tax Matter(s) above, for example, the authority to sign any agreements, consents or other
documents and to represent the taxpayer(s) in any informal or formal proceeding involving the Department of Revenue.
The authority of the representative(s) does not and cannot include the power to substitute another representative or to
request that tax return(s) or other confidential tax information of the taxpayer(s) be inspected by or disclosed to another
person.
The authority also does not include the authority to receive tax refund checks or to sign returns unless
specifically added below.
List any specific additions or deletions to the acts otherwise authorized by this Power of Attorney:
Additions:
____________________________________________________________________________________
Deletions:
____________________________________________________________________________________
The
Department of Revenue may reject a submission due to incompleteness, lack of specificity, or inappropriateness.
DEPARTMENT OF REVENUE
P.O. BOX 1033
JACKSON, MS 39215-1033
Phone: 601-923-7000
POWER OF ATTORNEY
AND
DECLARATION OF REPRESENTATION
Form 21-002-13
PART I POWER OF ATTORNEY
For DOR Use Only
Taxpayer(s) Information
Taxpayer Name(s) and Mailing Address
Taxpayer Social Security Number
Received by:
Name
__________________________
Spouse Social Security Number
Phone
_________________________
Federal ID Number (FEIN)
____________________
Date
Hereby appoint(s) the following representative(s):
Representative Information
Name and Mailing Address
(
)
Phone Number
_________________________________________________
(
)
FAX Number
_________________________________________________
Name and Mailing Address
(
)
Phone Number
________________________________________________
(
)
FAX Number
_________________________________________________
Name and Mailing Address
(
)
Phone Number
_________________________________________________
(
)
FAX Number
_________________________________________________
To represent the taxpayer(s) before the Mississippi Department of Revenue in:
Tax Matter(s)
Tax Type (Income, Franchise, Sales, Insurance Premium, etc.)
Account Number
Tax Period(s)
Acts Authorized
I (we) as the taxpayer(s) give authorization to the representative(s) to receive and inspect confidential tax information and
to perform any and all acts that the taxpayer(s) can perform with respect to the matters concerning the taxes and
accounts described under Tax Matter(s) above, for example, the authority to sign any agreements, consents or other
documents and to represent the taxpayer(s) in any informal or formal proceeding involving the Department of Revenue.
The authority of the representative(s) does not and cannot include the power to substitute another representative or to
request that tax return(s) or other confidential tax information of the taxpayer(s) be inspected by or disclosed to another
person.
The authority also does not include the authority to receive tax refund checks or to sign returns unless
specifically added below.
List any specific additions or deletions to the acts otherwise authorized by this Power of Attorney:
Additions:
____________________________________________________________________________________
Deletions:
____________________________________________________________________________________
The
Department of Revenue may reject a submission due to incompleteness, lack of specificity, or inappropriateness.
DEPARTMENT OF REVENUE
P.O. BOX 1033
JACKSON, MS 39215-1033
Phone: 601-923-7000
DOR Power of Attorney, Form 21-002
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 Department of
Revenue for the same tax matter(s) covered by this document. If you do not want to revoke a prior Power or Attorney,
check here
and ATTACH A COPY OF THE POWER(S) OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.
Who Must Sign and What Documentation of Authority Must Be Attached
If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested. A corporation
or subsidiary MUST contain the signatures of a principal officer and the secretary or other officer. A guardian, executor,
receiver, administrator, conservator or trustee MUST attach the appropriate documentation granting the authority from the
court or taxpayer.
Signing is Certification Under Oath Subject to Penalty of Perjury
The person(s) signing this Power of Attorney and Declaration of Representations certifies under oath that all the
information contained in this document is true and correct and that he, she or they have the authority to sign this
document as the taxpayer(s) or on behalf of the taxpayer(s) and acknowledge that this Power of Attorney and Declaration
of Representation is being signed under the penalty of perjury pursuant to Miss. Code Ann. § 27-3-83(5).
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
Signature
Date
Title (if applicable)
Print Name
Phone Number
FAX Number
Signature
Date
Title (if applicable)
Print Name
Phone Number
FAX Number
PART II DECLARATION OF REPRESENTATIVE
Under penalties of perjury and Miss. Code Ann. §97-7-10, I declare that:
1) I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there: and
2) 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 authorized to practice as a certified public accountant in the jurisdiction shown.
c. Officer – a bona fide officer of the taxpayer’s organization.
d. Full-time employee – a full time employee of the taxpayer.
e. Family Member – a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister).
f. Enrolled Agent – enrolled as an agent under the requirements of the IRS.
g. Other – Provide explanation ________________________________________________________________
F NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
I
Designation – Insert
State Issuing
State License
Signature
Date
Above letter (a-g)
License
Number
DEPARTMENT OF REVENUE
P.O. BOX 1033
JACKSON, MS 39215-1033
Phone: 601-923-7000
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