Missouri Department of Revenue Power of Attorney Form

Click Here to Download This form is commonly used when filing Missouri annual taxes and you would like someone to represent you (Example: Accountant).

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Form (s) _______________ Only
Each attorney-in-fact is authorized, subject to revocation, to receive confidential information and perform any and all acts that the taxpayer(s)
can perform with respect to the above specified tax matters, but not the power to endorse or receive checks in payment of any refunds or to
represent the taxpayer/business in any proceeding before the Administrative Hearing Commission.
Information involving the above tax matter(s) may be sent as indicated below:  Failure of representative to receive notice does not relieve the
taxpayer of responsibility to respond to notices.
1. The representative first named above; or
2. The following named representative(s) (no more than two):
Revocation of prior Powers of Attorney (Must check one of the boxes below)
All other powers of attorney on file with the Department shall remain in effect; or
By execution of this power of attorney, all earlier powers of attorney on file with the Department are hereby revoked, except the following:
(specify to whom the power of attorney was granted, date and address, or refer to attached copies of earlier powers of attorney and authorizations.) Attach additional forms if needed.
DOR-2827 (07-2012)
MISSOURI DEPARTMENT OF REVENUE
POWER OF ATTORNEY
TAXPAYER’S NAME OR BUSINESS NAME SOCIAL SECURITY NUMBER/FEDERAL I.D. NUMBER
SPOUSE’S NAME OR IF A D/B/A, STATE THE BUSINESS NAME   SPOUSE’S SSN/FEDERAL I.D. NUMBER
STREET ADDRESS MISSOURI TAX I.D. NUMBER
CITY OR TOWN, STATE, ZIP CODE TELEPHONE NUMBER MISSOURI CHARTER NUMBER
E-MAIL ADDRESS
TAXPAYER(S) HEREBY APPOINTS (Please print or type – attach additional forms if needed)
PLEASE TYPE OR PRINT(Submission of a DOR-2827, Power of Attorney, by a taxpayer is not in itself sufficient as official notice to the
Department of Revenue of an address change.)
NAME OF APPOINTED REPRESENTATIVE ADDRESS
TELEPHONE NUMBER E-MAIL
NAME OF APPOINTED REPRESENTATIVE ADDRESS
TELEPHONE NUMBER E-MAIL
NAME OF APPOINTED REPRESENTATIVE ADDRESS
TELEPHONE NUMBER E-MAIL
NAME OF APPOINTED REPRESENTATIVE ADDRESS
TELEPHONE NUMBER E-MAIL
as attorney(s)-in-fact to represent taxpayer(s) before the Missouri Department of Revenue, with respect to the following tax matter(s) (the tax
type and year(s) to which this form applies must be listed below):
TYPE OF TAX
YEAR(S) OR PERIOD(S)
(DATE OF DEATH IF ESTATE TAX)
Note: All appointed representatives must sign on reverse side of this form.
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Withholding      Individual
Sales/Use Motor Fuel
Corporate Income/Franchise   Other ________________
Cigarette/Other Tobacco Products
MISSOURI TAX FORMS
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All Periods
Tax Year/Period(s) Only _____________
______________  to  _______________
Date of death  _____________________NAME OF REPRESENTATIVE SIGNATURE OF REPRESENTATIVE DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE) JURISDICTION (STATE, ETC.)
1. 2. 3. 4. 5. 6. 7. 8.
NAME OF REPRESENTATIVE SIGNATURE OF REPRESENTATIVE DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE) JURISDICTION (STATE, ETC.)
1. 2. 3. 4. 5. 6. 7. 8.
NAME OF REPRESENTATIVE SIGNATURE OF REPRESENTATIVE DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE) JURISDICTION (STATE, ETC.)
1. 2. 3. 4. 5. 6. 7. 8.
NAME OF REPRESENTATIVE SIGNATURE OF REPRESENTATIVE DATE
DESIGNATION (PLEASE CIRCLE APPROPRIATE NUMBER FROM LIST ABOVE) TITLE (IF APPLICABLE) JURISDICTION (STATE, ETC.)
1. 2. 3. 4. 5. 6. 7. 8.
DOR-2827 (07-2012)
SIGNATURE OF, OR FOR, TAXPAYER(S)
I (we) hereby certify that I (we) am (are) the taxpayer(s) named herein or that I have the authority to execute this power of
attorney on behalf of the taxpayer(s).
NAME TITLE (IF APPLICABLE)
SIGNATURE DATE TAXPAYER TELEPHONE NUMBER
NAME TITLE (IF APPLICABLE)
SIGNATURE DATE TAXPAYER TELEPHONE NUMBER
Please consult Missouri Regulation 12 CSR 10-41.030 for any questions about who may serve as an attorney(s)-in-fact and
what additional documentation may be required.
I declare that I am aware of Regulation 12 CSR 10-41.030 and that I am one of the following:
1. a member in good standing of the bar of the highest court of the jurisdiction indicated below;
2. a certified public accountant duly qualified to practice in the jurisdiction indicated below;
3. an officer of the taxpayer organization;
4. a full-time employee of the taxpayer;
5. a fiduciary for the taxpayer;
6. an enrolled agent;
7. tax preparer; or
8. other authorized representative or agent
and that I am authorized to represent the taxpayer(s) identified above for the tax matters there specified.
Note: All appointed representatives must sign below.
DECLARATION OF REPRESENTATIVE
Please send completed forms to:
Missouri Department of Revenue Missouri Department of Revenue Missouri Department of Revenue Missouri Department of Revenue
Taxation Division Taxation Division Taxation Division Taxation Division
PO Box 357 PO Box 2200 PO Box 300 PO Box 811
Jefferson City, MO  65105-0357 Jefferson City, MO  65105-2200 Jefferson City MO 65105-0300 Jefferson City MO 65105-0811
Fax:  (573) 522-1722 Fax:  (573) 751-2195 Fax:  (573) 522-1720 Fax:  (573) 522-1720
(If reporting Business Tax) (If reporting Personal Tax) (If reporting Motor Fuel Tax) (If reporting Cigarette Tax or
Other Tobacco Products Tax)
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