CLEAR FORM

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                                                                    INCOME TAX DEPARTMENT POWER OF 
                                                                    ATTORNEY AUTHORIZATION 

PART 1:   TAXPAYER INFORMATION 
Taxpayer's Name and Address (include spouse's name if joint return) Taxpayer SSN                                                 Spouse SSN 

                                                                    If a business, enter DBA, trade or assumed name 

                                                                    Telephone Number                                             Fax Number 

                                                                    E-mail Address 

PART  2:  REPRESENTATIVE  INFORMATION  AND  AUTHORIZATION DATES 
Representative's Name and Address                                   Contact Name (if applicable)                                 E-mail Address 

                                                                    Telephone Number                                             Fax Number 

                                                                    Beginning Authorization Date                                 Ending Authorization Date* 

PART 3: TYPE OF  AUTHORIZATION 

          GENERAL  AUTHORIZATION 
          Authorizes my representative to: (1) inspect or receive confidential information; (2) represent me and make oral 
          or written presentations of fact and argument; (3) sign returns; (4) enter into agreements; (5) receive mail 
          (includes forms, billings and payment notices). This authorization applies to all tax matters for all tax years or 
          periods. 

          LIMITED  AUTHORIZATION 
          Select the type of authorization by checking the appropriate boxes. 
                                                                                                                                 All Tax        Only as Specified 
                                                                                                                                 Matters            Below 
          1. Inspect  or  receive  confidential  information........................................................
          2. Represent me  and make  oral  or  written presentations  of fact and argument...
          3. Sign  returns.......................................................................................................
          4. Enter  into  agreements.......................................................................................
          5. Receive mail (includes forms, billings and payment notices)............................

Type of Income Tax                 Tax Form or Invoice Number                                                                    Tax Year(s) or Period(s)    

PART 4: CHANGE IN POWER OF ATTORNEY REPRESENTATION OR REVOCATION 

          CHANGE IN POWER OF ATTORNEY REPRESENTATION: This form replaces all earlier Powers of Attorney, 
          except those attached, on file for the same tax matters and years or periods covered by this Power of Attorney. 

          REVOKE PREVIOUS AUTHORIZATION: I revoke all Powers of Attorney submitted and will represent myself in 
          all tax matters. Attach copies of all Powers of Attorney that will remain in effect concurrent with this new 
          authorization. 
PART  5:  TAXPAYER'S SIGNATURE'S   
If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer, I certify that I have the authority to execute 
this Power of Attorney. 
Signature                                                           Name or Title Typed or Printed                                             Date 

Spouse's  Signature                                                 Name or Title Typed or Printed                                             Date 

* If no ending authorization date is provided, the above-named representative will be authorized to represent you until you
notify the Income Tax Department in writing that this Power of Attorney is revoked.

Mail to: City of Springfield 601 Avenue A Springfield MI 49015-1499