Kentucky Kentucky Tax Declaration of Representative / Power of Attorney

Kentucky Tax Declaration of Representative / Power of Attorney
Form 20A100
FORM

20A100
DECLARATION OF REPRESENTATIVE

Com m onw ealth of Kentucky
Department of Revenue

1 TAXPAYER INFORM ATION: Please type or print.

Enter only those that apply.

Taxpayer Nam e

Federal Taxpayer Identifi cation Num ber

M ailing Address - Num ber and Street

City

State

Apartm ent/Suite No.

Zip Code

E-m ail Address

Daytim e Phone

2 REPRESENTATIVE(S) INFORM ATION

Enter applicable identifi cation num ber.

Nam e

State and State Bar Num ber

M ailing Address - Num ber and Street

City

State

Apartm ent/Suite No.

Zip Code

State and CPA License Num ber

Daytim e Phone

IRS Enrolled Agent Num ber

Nam e

State and State Bar Num ber

M ailing Address - Num ber and Street

City

State

Apartm ent/Suite No.

Zip Code

State and CPA License Num ber

Daytim e Phone

IRS Enrolled Agent Num ber

Nam e

State and State Bar Num ber

M ailing Address - Num ber and Street

City

State

Apartm ent/Suite No.

Zip Code

State and CPA License Num ber

Daytim e Phone

IRS Enrolled Agent Num ber

3 TAX M ATTERS: The taxpayer appoints the above representative(s) for purposes of duly authorized representation
in any proceeding w ith the Kentucky Departm ent of Revenue w ith respect to the tax m atters indicated below. If no tax
form num ber or tax year is provided, this form w ill be valid for all tax types, tax years, and authorized acts selected
until revoked.
TAX TYPE

¨

Corporation Incom e/Lim ited Liability
Entity Tax

¨

Individual Income Tax

¨

Sales and Use Tax

¨

Property Tax

¨

Other (Please Specify)

ACCOUNT NUM BER

TAX FORM NUM BER
(740, 720, 51A205, etc.)

TAX YEAR(S) OR PERIOD(S)

4 AUTHORIZED ACTS: The representative(s) listed above is authorized to receive, inspect, and discuss the
taxpayer ’s confi dential tax inform ation. The taxpayer also authorizes the follow ing acts:

¨

Representative has the authority to sign a statute of lim itations waiver on Taxpayer’s behalf.

¨

Representative has the authority to execute a protest on Taxpayer’s behalf.

¨

Representative has the authority to represent Taxpayer in any adm inistrative tax proceeding, including conferences.

¨

Representative has the authority to receive notices and com m unications (unless system generated) from the Departm ent of
Revenue.

¨

Representative has the authority to represent Taxpayer in any collection m atter, including an Offer-in-Settlem ent.

¨

Representative m ay obtain Taxpayer's MyTaxes PIN and execute changes to Taxpayer’s account.

¨

Other acts. (Please specify) ________________________________________________________________________________________

20A100 (10-19)

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FORM 20A100

DECLARATION OF REPRESENTATIVE

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5 CONSOLIDATED OR UNITARY COM BINED RETURN FILERS: If the taxpayer fi les a consolidated or unitary com bined
tax return per KRS 141.200(11) and/or KRS 141.201(3)(a), the authorized acts w ill be extended to the subsidiaries
included in the return. If any subsidiaries are to be excluded from the authorized acts, list below.
NAM E

FEDERAL IDENTIFICATION
NUM BER

TAX YEARS

6 RETENTION/ REVOCATION OF PRIOR POWER(S) OF ATTORNEY OR REPRESENTATIVE AUTHORIZATION(S)
The fi ling of this authorization form autom atically revokes any prior pow er(s) of attorney or representative authorization(s) on fi le
w ith the Departm ent of Revenue for the sam e m atter(s) and year(s) or period(s) covered by this docum ent. If you do not want to
revoke any prior pow er(s) of attorney or representative authorization(s), you must attach a copy of any power(s) of attorney or
representative authorization(s) you w ish to remain in effect for the same matter(s) and year(s) or period(s) covered.

7

SIGNATURE OF TAXPAYER. If a tax m atter concerns a year in w hich a joint return was fi led, each spouse m ust fi le a separate
representative authorization even if they are appointing the sam e representative(s). If signed by a corporate offi cer, partner,
guardian, tax m atters partner, executor, receiver, adm inistrator, or trustee on behalf of the taxpayer, I certify that I have the legal
authority to execute this form on behalf of the taxpayer.
NOT VALID UNLESS COM PLETED, SIGNED, AND DATED BY THE TAXPAYER.

Signature

Date Signed

Print Nam e

Title (if applicable)

8

SIGNATURE OF REPRESENTATIVE(S)

Under penalties of perjury, by my signature below I declare that:
•
I am not currently suspended or disbarred from practice, or ineligible for practice;
•
I am subject to regulations contained in Circular 230 (31 CFR, Subtitle A, Part 10) as am ended, governing practice before the
Internal Revenue Service;
•
I am authorized to represent the taxpayer for the m atter(s) specifi ed; and
NOT VALID UNLESS COM PLETED, SIGNED, AND DATED BY THE REPRESENTATIVE(S).
Signature

Date Signed

Printed Nam e

PTIN (if applicable)

Signature

Date Signed

Printed Nam e

PTIN (if applicable)

Signature

Date Signed

Printed Nam e

PTIN (if applicable)

Instructions for Form 20A100

FORM 20A100

4

Purpose of Form 20A100
Use the Declaration of Representative (Form 20A100)
to authorize the individual(s) to represent you before
the Kentucky Departm ent of Revenue. You m ay grant
the individual(s) authorization to act on your behalf
w ith regard to any tax adm inistered by the Kentucky
Departm ent of Revenue. Form 20A100 is provided for
the taxpayer’s convenience. One form m ay be subm itted
to designate all tax types the Departm ent is authorized
to com m unicate w ith the authorized representative(s).
You m ay revoke this form at any tim e.
1

Taxpayer Information—enter the follow ing:

Note: This form does not allow the authorized
representative to sign tax returns or settlement
agreements on your behalf.

Name and Address—Print or type the nam e of the
taxpayer subm itting this form . For the address,
include the suite, room , or other unit num ber after
the street address. If the U.S. Postal Service does not
deliver to the street address and the taxpayer has
a P.O. box, include the box num ber instead of the
street address.

2

the

taxpayer’s

6

Retention/ Revocation
Filing this form w ill autom atically revoke any prior
pow er of attorney or authorization letter subm itted
to the Departm ent for the tax m atters included on
this form . If you do not want to revoke a prior power
of attorney or authorization letter, a copy M UST be
attached to this form to remain in effect.

e-m ail
7

Tax M atters
Select the tax types the authorized representative(s)
may act on your behalf w ith the Departm ent. Provide
the account num ber for all tax types selected. If
authorization is being granted for specifi c form s and
tax periods, list the tax form s and tax periods. If tax
form s and tax periods are left blank, this form w ill
be valid for all tax types, tax periods, and authorized
acts selected until revoked.

Signature of Taxpayer
This form m ust be signed and dated by the taxpayer
to be valid. If the taxpayer is a business entity, it
m ust be signed by an individual w ith the authority
to delegate a representative on behalf of the
taxpayer. If not signed and dated, the Departm ent
w ill not com m unicate w ith or provide confi dential
tax inform ation to the authorized representative(s)
included on this form .

Representative Information
Enter up to three individuals authorized to represent
you and act on your behalf before the Departm ent
about the tax m atters and authorized acts specifi ed on
this form. Provide the nam e, address, and telephone
num ber of the authorized representative(s). If the
authorized representative is an attorney, certifi ed
public accountant (CPA), or enrolled agent, provide
the appropriate identifi cation num ber.

3

Consolidated or Unitary Combined Return Filers
If a consolidated or unitary com bined tax return has
been fi led, list any subsidiary(ies) to be excluded
from this authorization. The Departm ent w ill not
discuss or provide confi dential tax inform ation to
the authorized representative(s) for any subsidiary
listed. If no subsidiaries are listed, this form w ill
extend to all corporations in a consolidated or
unitary com bined tax return.

Federal Taxpayer Identification Number—Enter
the federal identifi cation num ber. For individuals,
this w ill be your social security num ber. For
business entities, this w ill be your federal em ployer
identifi cation num ber (FEIN).
E-mail Address—
Enter
address.

Authorized Acts
This form allow s the authorized representative(s)
to com m unicate and receive confi dential tax
inform ation. You m ay also select other acts the
authorized representative(s) m ay perform on your
behalf. If an act is not listed, select “Other” and
specify.

5

Daytime Phone—Enter the taxpayer’s telephone
num ber.

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8

Signature of the Authorized Representative(s)
This form m ust be signed and dated by the
authorized representative(s) to be valid. If not signed
and dated, the Departm ent w ill not com m unicate
w ith or provide confi dential tax inform ation to the
authorized representative(s) included on this form .
M ail this form to the follow ing address:

Kentucky Department of Revenue
P. O. Box 181, Station 56
Frankfort, Kentucky 40602-0181