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      Utah State Tax Commission
      210 N 1950 W, SLC, UT 84134  •  tax.utah.gov  •  801-297-2200  •  fax: 801-297-3573                             TC-737
                                                                                                                      Rev. 7/15
      Power of Attorney and Declaration of Representative 

1. Taxpayer Information (Provide information for only one taxpayer per form)
 Name                                                                          Identification number(s)

 Address                                                                       Daytime telephone number(s)  Fax number

 City                                      State    ZIP Code                   Email address

2. Representative(s)
 I hereby appoint the following representative(s) as attorney(s)-in-fact: (attach additional pages if needed)
 Name and address                                    
                                                                               Telephone:
                                                                               Fax number:
                                                                               Email:
 Name and address                                    
                                                                               Telephone:
                                                                               Fax number:
                                                                               Email:

3. Tax matter(s)
 This declaration authorizes the representative(s) to receive and inspect my confidential tax information and, to the extent not limited in 
 section 4 below, to perform any acts that I can with respect to the tax matter(s) listed below in this section. This power does not include 
 the power to receive funds, substitute or appoint another representative, or disclose confidential tax information to other parties.
 Tax Type            Social Security/Account Number Year(s) or Period(s)                  Appeal Number(s)
 _______ _________________                          __________                            ____________________
 _______ _________________                          __________                            ____________________
 _______ _________________                          __________                            ____________________

4. Acts NOT Authorized (Check only the boxes of those acts for which authority is NOT given)
 My representative(s) is NOT authorized to perform the following acts which would otherwise be authorized:
  Sign returns            Amend returns  Negotiate agreements                Sign agreements/consents/similar documents
   Reallocate payments between tax types/periods    Represent me in adjudicative proceedings before the Commission
  Facilitate audits        Other: _______________________________________________

5. Authorized Signature
 Unless you check the box below, filing this power-of-attorney will revoke all earlier power(s)-of-attorney on file with the Tax Commission 
 for the same matters and years/periods covered in this document.
   Check this box if you do not wish to revoke all prior power(s)-of-attorney.

 ___________________________________________                                                ______________
 Taxpayer signature                                                                         Date
 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 on behalf of the taxpayer.

 __________________________                          _______________                        ______________
 Representative signature                            Title                                  Date