Revised 09/26/2013 
                                              City of Grand Rapids 
                                       Income Tax Department 
                                                            
            INSTRUCTIONS FOR POWER OF ATTORNEY AUTHORIZATION 
 
Complete and file a Power of Attorney Authorization if you wish to appoint an individual, firm or organization as 
your representative in income tax matters before the Income Tax Department of the City of Grand Rapids. 
Failure to complete this form will prohibit the Income Tax Department from discussing or releasing your tax 
return and/or tax return information with or to another person including your spouse. 
 
PART 1: TAXPAYER INFORMATION                                3.  Check this box if your representative is authorized to 
Enter the taxpayer’s name, address, telephone number,        sign tax returns. 
fax number  and  e-mail address  (if applicable). If the    4.  Check this box if your representative is authorized to 
taxpayer is a business operating  under another name,        enter into agreements (such as payment plans). 
enter the DBA, trade or assumed name. Enter the Social      5.  Check this box if your representative is authorized to 
Security number(s), federal employer  identification         receive mail. 
number (FEIN) or other  account  number, whichever           
applies. If spouses  are designating the  same              PART 4: CHANGE IN POWER OF ATTORNEY 
representative, enter the spouse’s name, address  (if       REPRESENTATION OR REVOCATION 
different) and Social Security number.                      Unless otherwise specified, this Power of Attorney 
                                                            Authorization replaces and revokes any previous power 
PART 2: REPRESENTATIVE INFORMATION                          of attorney  authorizations on file  with the Income Tax 
AND AUTHORIZATION DATES                                     Department of the city noted above for the same tax 
You must  send a  separate Power of  Attorney form for      matters identified on this form.  
each different representative. Enter the authorized          
representative’s name firm’s name, address, telephone       You must identify any previous authorizations that are to 
number, fax number, and e-mail address (if applicable).     remain in effect, and attach a copy of the authorizations 
If your representative is  not an individual, designate a   to this form when filed.  
contact person. Indicate the beginning and ending dates      
of authorization.                                           PART 5: TAXPAYER SIGNATURE 
                                                            You, and if  a joint return, your spouse must sign  and 
PART 3: TYPE OF AUTHORIZATION                               date the form.  
Check the  General Authorization  box to allow your          
representative to act on  your behalf to do all of the      FILING 
following:                                                  Mail this form to: 
1.  Inspect and receive confidential information;            Grand Rapids Income Tax Department 
2.  Represent  you and  make oral or  written                PO Box 347 
 presentations of fact and argument;                         Grand Rapids, MI  49501-0347 
3. Sign returns;                                             
4.  Enter into agreements; and 
5.  Receive all mail including forms, billings and 
 payment notices. 
 
This authorization applies to all income tax matters 
for all years and tax periods. 
 
You may restrict your representative’s authorization  to 
act on your behalf  by checking the               Limited 
Authorization box, and checking the appropriate boxes. 
To limit the authorization to specific income tax matters, 
check the appropriate “Only as Specified Below” boxes, 
and indicate the type of income tax, type of income tax 
form, and tax years or periods for which you are granting 
authorization in the space provided. 
1.  Check this box if your representative is authorized to 
 inspect or receive confidential information. 
2.  Check this box if your representative is authorized to 
 represent you and make oral or written presentation 
 of fact and argument.