GR-2848                                                 CITY OFGRAND RAPIDS INCOME TAX DEPARTMENT
                                                             Power of Attorney Authorization
Issued under Authority of the Uniform City Income Tax Ordinance (MCL 141.601 et seq.)  Filing is voluntary.
Complete this form if you wish to appoint someone to represent you to the Income Tax Department on income tax matters, or if you wish to revoke or change 
your current power of attorney authorization. Read the instructions on page 2 before completing this form.
                                                                                                                                        Revised: 05/01/2013
PART 1:  TAXPAYER INFORMATION
Taxpayer's (first name, initial, last name or business name)                Taxpayer SSN/FEIN

If joint return spouse's first name, initial, last name                     Spouse SSN

Current address (number and street)                          Apt./Ste. no.  If a business, enter DBA, trade or assumed name

Address line 2                                                              Telephone number                        Fax number

City, town or post office           State               Zip code            E-mail address

Foreign country name, province/county, postal code

PART 2:  REPRESENTATIVE INFORMATION AND AUTHORIZATION DATES
Representative's name                                                       Contact's name (if applicable)          Contact's name (if applicable)

Firm name                                                                   E-mail address                          E-mail address

Address (number and street)                                  Apt./Ste. no.  Telephone number                        Telephone number

Address line 2                                                              Fax number                              Fax number

City, town or post office           State               Zip code            Beginning authorization date (MM/DD/YY) Ending authorization date (MM/DD/YY)*

Foreign country name, province/county, postal code

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 including forms, billings and payment notices.  This authorization applies to all 
  tax matters for all tax years or periods. 
  LIMITED AUTHORIZATION                                                                                             All Tax   Only as 
  Select the type of authorization by checking the appropriate boxes.                                               Matters   Specified 
                                                                                                                              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 Assessment 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 remain in effect concurrent with this new authorization.
PART 5:  TAXPAYER 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.