Clear Form Tax Information Authorization and For Office Use Only Power of Attorney for Representation Date received • Please print. • Use only blue or black ink. • See additional information on the back. Taxpayer name Identifying number (SSN, BIN, FEIN, etc.) Spouse’s/registered domestic partner’s (RDP) name, if joint return Spouse’s/RDP’s identifying number (SSN, etc.) Address City State ZIP code Check only one: Tax Information Authorization: Checking this box allows the department to disclose your confidential tax information to your designee. You may designate a person, agency, firm, or organization. Power of Attorney for Representation: Check this box if you want a person to “represent” you. This means the person may receive confidential information and may make decisions on your behalf. The person you designate must meet the qualifications listed on the back of this form. For All tax years, or Specific tax years: ___________________________________________________________________ , I hereby appoint the following person as designee or authorized representative: Name Fax number Telephone number () Mailing address () State City ZIP code Representative’s title and Oregon license number or relationship to taxpayer If out-of-state CPA, sign here attesting you meet the requirements to practice in Oregon (see instructions) The above named is authorized to receive my confidential tax information and/or represent me before the Oregon Department of Revenue for: All tax matters, or Specific tax matters. Enter tax program name(s):_________________________________________________________________________ Signature of Taxpayer(s) •I acknowledge the following provision: Actions taken by an authorized representative are binding, even if the representative is not an attorney. Proceedings cannot later be declared legally defective because the representative was not an attorney. •Corporate officers, partners, fiduciaries, or other qualified persons signing on behalf of the taxpayer(s): By signing, I also certify that I have the authority to execute this form. •If a tax matter concerns a joint return, both spouses/RDPs must sign if joint representation is requested. Taxpayers filing jointly may authorize separate representatives. Signature Print name Date X Daytime telephone number Title (if applicable) () Spouse/RDP (if joint representation) Print name Date X Note: This authorization form automatically revokes and replaces all earlier tax authorizations and/or all earlier powers of attorney on file with the Oregon Department of Revenue for the same tax matters and years or periods covered by this form. If you do not want to revoke a prior authorization, initial here ______. Attach a copy of any other tax information authorization or power of attorney you want to remain in effect. Please complete the following, if known (for routing purposes only): Revenue Employee:__________________________________________________ Division/Section:_____________________________________________________ Telephone/Fax:_______________________________________________________ Send to: Oregon Department of Revenue 955 Center St NE Salem OR 97301-2555 If this tax information authorization or power of attorney form is not signed, it will be returned. 150-800-005 (Rev. 12-10) Additional information 3. For ad valorem property tax issues: This form is used for two purposes: a.All those listed in (1); plus b.An Oregon licensed real estate broker or a principal real estate broker; or c. An Oregon certified, licensed, or registered appraiser; or d.An authorized agent for designated utilities and companies assessed by the department under ORS 308.505 through 308.665 and ORS 308.805 through 308.820. • Tax information disclosure authorization. You authorize the department to disclose your confidential tax information to another person. This person will not receive original notices we send to you. • Power of attorney for representation. You authorize another person to represent you and act on your behalf. The person must meet the qualifications below. Unless you specify differently, this person will have full power to do all things you might do, with as much binding effect, including, but not limited to: providing information; preparing, signing, executing, filing, and inspecting returns and reports; and executing statute of limitation extensions and closing agreements. This form is effective on the date signed. Authorization terminates when the department receives written revocation notice or a new form is executed (unless the space provided on the front is initialed indicating that prior forms are still valid). Unless the appointed representative has a fiduciary relationship to the taxpayer (i.e., personal representative, trustee, guardian, conservator), original Notices of Deficiency or Assessment will be mailed to the taxpayer as required by law. A copy will be provided to the appointed representative when requested. 4. For forestland and timber tax issues: a.All those listed in (1), (2), and (3)(b) and (c); plus b.A consulting forester. An individual who prepares and either signs your tax return or who is not required to sign your tax return (by the instructions or by rule), may represent you during an audit of that return. That individual may not represent you for any other purpose unless they meet one of the qualifications listed above. Generally, declarations for representation in cases appealed beyond the Department of Revenue must be in writing to the Tax Court Magistrate. A person recognized by a Tax Court Magistrate will be recognized as your representative by the department. For corporations, “taxpayer” as used on this form, must be the corporation that is subject to Oregon tax. List fiscal years by year end date. Tax matters partners and S corporation shareholders. See OARs 150-305.242(2) and (5) and 150-305.230 for additional information. Include the partnership or S corporation name in the taxpayer name area. Qualifications to represent taxpayer(s) before Department of Revenue Out-of-state attorneys and CPAs Under Oregon Revised Statute (ORS) 305.230 and Oregon Administrative Rule (OAR) 150-305.230, a person must meet one of the following qualifications in order to represent you before the Department of Revenue. 1. For all tax programs: a.An adult immediate family member (spouse/RDP, parent, child, or sibling). b.An attorney qualified to practice law in Oregon. c. A certified public accountant (CPA) or public accountant (PA) qualified to practice public accountancy in Oregon, and their employees. d.An IRS enrolled agent (EA) qualified to prepare tax returns in Oregon. e. A designated employee of the taxpayer. f. An officer or full-time employee of a corporation (including a parent, subsidiary, or other affiliated corporation), association, or organized group for that entity. g.A full-time employee of a trust, receivership, guardianship, or estate for that entity. h.An individual outside the United States if representation takes place outside the United States. 2. For income tax issues: a.All those listed in (1); plus b.A licensed tax consultant (LTC) or licensed tax preparer (LTP) licensed by the Oregon State Board of Tax Practitioners. 150-800-005 (Rev. 12-10) Attorneys may contact the Oregon State Bar for information on practicing in Oregon. If your out-of-state representative receives authorization to practice in Oregon, please attach proof to this form. CPAs may practice in Oregon if they meet the following substantial equivalency requirements of ORS 673.010: 1. Licensed in another state; 2. Have an accredited baccalaureate degree with at least 150 semester hours of college education; 3. Passed the Uniform CPA exam; and 4. Have a minimum of one year experience. Taxpayer assistance General tax information......................www.oregon.gov/dor Salem.................................................................. 503-378-4988 Toll-free from an Oregon prefix................... 1-800-356-4222 Asistencia en español: Salem.................................................................. 503-378-4988 Gratis de prefijo de Oregon......................... 1-800-356-4222 TTY (hearing or speech impaired; machine only): Salem.................................................................. 503-945-8617 Toll-free from an Oregon prefix................... 1-800-886-7204 Americans with Disabilities Act (ADA): Call one of the help numbers for information in alternative formats.
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