CITY OF GRAND RAPIDS
                         INCOME TAX DEPARTMENT
                     POWER OF ATTORNEY AUTHORIZATION
1.Taxpayer Name                                      Phone Number                                            Account Number
  Address                                                                                                 City                                          State                     ZIP Code

  NOTE:      Use item 7 to revoke an existing power of attorney.
                                                                                 From: (mo/day/yr)           To: (Expiration)*
2.This Power of Attorney Authorization is effective only for the inclusive dates:                /          /             /         /
3.Your authorized representative(s).  This may be an organization, firm, partnership or individual.  If your
  representative is not an individual, you must designate a contact person.  Submit additional forms if you have
  more than two representatives.  We will contact either representative unless you attach a letter specifying joint
  contacts.
  Representative Name                                                                                        Telephone Number
  Address                                                                                                   City                                         State                      ZIP Code

  Representative Name                                                                                        Telephone Number
  Address                                                                                                   City                                         State                     ZIP Code

4.General Authorization.  My representative(s) is authorized to receive information and represent me as
  indicated below (you must check a box for every item).
   yes     no
  aq       q   To inspect or receive confidential tax information for all tax matters and years.
               If no, complete item 5 below.
   yes     no
  bq       q   To represent me and make oral or written presentations of fact or argument on my behalf
               for all tax matters and years.  If no, complete item 5 below.
   yes     no
  cq       q   To sign returns and enter into agreements for me for all tax matters and years.
               If no, complete item 5 below.
   yes     no
  dq       q   Other authorization as specified here:
5.Specific Authorization.  Complete only if you check “no” to any statement in item 4.
                                     Type of Grand Rapids Return                                             Tax Years or Tax Periods
  a
  b
  c
  d
6.New Power of Attorney.  This power of attorney revokes all earlier powers of attorney and tax information
  authorization on file with the City of Grand Rapids Income Tax Department for the same tax matters and years
  or periods covered by this power of attorney, except the following (specify person granted to, date and address
  including ZIP code, or refer to attached copies of earlier powers and authorizations):

7.No Power of Attorney.  I revoke all powers of attorney previously submitted and                            Initials
  will represent myself in all tax matters.  Initial here and complete item 8.

8.Taxpayer’s   If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer,
  Signature    I certify that I have the authority to execute this power of attorney.
  Signature                                 Print or Type Name                                               Date

  Signature                                 Print or Type Name                                               Date

  *If this matter is not settled by the expiration date, you may have to file a new power of attorney.