Tax Representation Mandate Form

TAX REPRESENTATION MANDATE FORM

Taxpayer Identification

Individual / Sole Proprietor
C Corporation
S Corporation
Partnership
Trust / Estate
LLC
Other

Taxpayer Identification Number

Provide either Social Security Number (SSN) or Employer Identification Number (EIN). Do not provide both unless required by law.

Representative Appointment

The taxpayer appoints the following representative(s) to act on behalf of the taxpayer with respect to the tax matters and periods specified below. The representative(s) shall have authority as set forth in this mandate.

Audit/examination representation
Collection matters and installment agreements
Appeals and administrative protest
Access to confidential tax information and transcripts
Sign consents, waivers, and limited agreements on behalf of taxpayer
File refund claims and amended returns
Other

Tax Matters and Periods

Tax Type(s):

Tax years or periods covered by this mandate:

Effective date of this mandate:     Termination date (if any):

Mandate Terms, Limitations and Certifications

1. Appointment: The taxpayer appoints the representative named above to represent the taxpayer before tax authorities with respect to the matters and periods specified herein. The representative is authorized to obtain and inspect confidential tax information, to correspond with tax authorities, and to take actions reasonably necessary to perform representation subject to the express limitations in this mandate.

2. Authority Limitations: This mandate does not authorize the representative to sign original tax returns unless expressly indicated in the scope of representation. Any power to sign returns or substitute for the signature of the taxpayer must be set forth expressly and in writing.

3. Receipt of Information: The taxpayer authorizes the release of tax information and return transcripts to the representative. The representative may receive copies of notices, determinations, and correspondence relating to the authorized matters and may provide information and documentation to tax authorities on the taxpayer’s behalf.

4. Duration and Revocation: This mandate remains in effect until the mandate termination date specified above, until the specified matters are finally resolved, or until revoked in writing by the taxpayer. Revocation takes effect upon receipt by the representative and tax authorities.

5. Indemnity and Reliance: The taxpayer agrees to indemnify and hold harmless the representative for actions taken reasonably and in good faith under this mandate. Tax authorities and third parties may rely on a copy of this form as conclusive evidence of the authority granted.

6. Conflicts and Withdrawal: The representative shall disclose any known conflicts of interest and may withdraw if required by professional rules or by inability to fulfill duties. Withdrawal does not relieve the taxpayer of obligations under agreements entered into prior to withdrawal.

Certification (perjury statement)

Under penalties of perjury, I certify that I am the taxpayer (or an authorized officer, partner, owner, or fiduciary) for the taxpayer named above, that the information provided on this form is true, correct, and complete to the best of my knowledge, and that I authorize the representative to perform the duties set forth in this mandate. I understand that making a false statement subject to the penalties of perjury may subject me to civil and criminal penalties.

By signing below the taxpayer acknowledges and accepts the terms of representation, limitations, and indemnification set forth herein.

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