Tax Representative Authorization Form

Tax Representative Authorization Form
Authorize a representative to act on your behalf for tax-related matters by completing this form.
Taxpayer Full Name
First NameLast Name
Taxpayer Email Address
example@example.com
Taxpayer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Taxpayer Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Representative Full Name
First NameLast Name
Representative Email Address
example@example.com
Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Representative Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Relationship of Representative to Taxpayer
Scope of Authorization (Select all that apply)
Other
Duration of Authorization
If 'For a specific period', please specify the end date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Authorization
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Taxpayer Signature
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Should be Empty: