Form:BTA 0002 (Rev. 8/12) 

  PART I POWER OF ATTORNEY 
  Taxpayer(s) Information                                                                            For BTA Use Only 
  Taxpayer Name(s) and Mailing Address                   Taxpayer Social Security Number 
                                                                                                     Received by: 
                                                         Spouse Social Security Number               Name                          
                                                                                                     Phone                          
                                                         Federal ID Number (FEIN) 
                                                                                                     Date                          
  Hereby appoint(s) the following representative 
  Representative Information 
  Name and Mailing Address                                                                    
                                                          Phone Number                    (   )                                  
                                                          
                                                          FAX Number                      (   )                                  
  Name and Mailing Address                                                                    
                                                          Phone Number                    (   )                                  
                                                          
                                                          FAX Number                      (   )                                  
  Name and Mailing Address                                                                    
                                                          Phone Number                    (   )                                   
                                                          
                                                          FAX Number                       (  )                                  
  To represent the taxpayer(s) before the Mississippi Board of Tax Appeals 
  Matter(s)  Appealed 
  Tax Type (Income, Sales, etc.) or Other Matters,        Account Number                                          Tax Period(s) 
                                                                                                     
  Acts Authorized 
  The representatives are authorized to receive and inspect confidential tax information and to perform any and all acts that 
  I (we) can perform with respect to the matters concerning the taxes and accounts described under Matter(s) Appealed 
  above, for example, the authority to sign any agreements, consents or other documents and to represent the taxpayer(s) 
  in any informal or formal proceeding involving the Board of Tax Appeals. The authority of the representatives does not 
  and cannot include the power to substitute another representative or to request that tax return(s) or other confidential tax 
  information of the taxpayer(s) be inspected by or disclosed to another person. The authority also does not include the 
  authority to receive tax refund checks or to sign returns unless specifically added below. 
 
  List any specific additions or deletions to the acts otherwise authorized by this power of attorney: 
 
  Additions:                                                                                                           
 
  Deletions:                                                                                                           
 
  The Board of Tax Appeals may reject a submission due to incompleteness, lack of specificity, or inappropriateness. 
 
  Retention/revocation of Prior Power(s) of Attorney 
  The filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Board of Tax Appeals for 
  the same matter(s) appealed covered by this document. If you do not want to revoke a prior Power or Attorney, 
  check here               and ATTACH A COPY OF THE POWER(S) OF ATTORNEY YOU WANT TO REMAIN IN EFFECT. 
  Signature of Taxpayer(s) 
 
  MAIL TO:  BOARD OF TAX APPEALS                        501 N. West St., Ste. 601, Jackson, MS 39201     Phone: 601.359.6604

  BTA Power of Attorney                                                                                                                              
  If a tax matter(s) appealed concerns a joint return, both husband and wife must sign if joint representation is requested. If signed 
  by a corporate officer, partner, guardian, conservator, executor, receiver, administrator, conservator or trustee on behalf of the 
  taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer. A corporation or subsidiary MUST 
  contain  the  signatures  of  a  principal  officer  and  the  secretary  or  other  officer.  A  guardian,  executor,  receiver,  administrator, 
  conservator or trustee MUST attach the appropriate documentation granting the authority from the court or taxpayer. 
 
  IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED. 
 
                                      Signature                                       Date                     Title (if applicable) 

                                      Print Name                            Phone Number                       FAX Number 

                                      Signature                                       Date                     Title (if applicable) 

                                      Print Name                            Phone Number                       FAX Number 
 
  PART II DECLARATION OF REPRESENTATIVE                                                                                                               
  Under penalties of perjury and Miss. Code Ann. §97-7-10, I declare that: 
  1) I am authorized to represent the taxpayer(s) identified in Part I for the matter(s) appealed specified there: and 
  2) I am one of the following: 
     a. Attorney – a member in good standing of the bar of the highest court of the jurisdiction shown below. 
     b. Certified Public Accountant – duly authorized to practice as a certified public accountant in the jurisdiction shown. 
     c. Officer – a bona fide officer of the taxpayer’s organization. 
     d. Full-time employee – a full time employee of the taxpayer. 
     e. Family Member – a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister.) 
 
     f. Other – Provide explanation                                                                             
 
  IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED. 
 
  Designation – Insert   State Issuing           State License              Signature                                  Date 
     Above letter (a-f)         License          Number 
                                                                                                               
  MAIL TO:  BOARD OF TAX APPEALS                      501 N. West St., Ste. 601, Jackson, MS 39201     Phone: 601.359.6604