REV-677 LE (05-14)
                                           POWER OF ATTORNEY AND
                                                  DECLARATION OF
                                                  REPRESENTATIVE
 GENERAL INSTRUCTIONS:
 This form provides limited authority for department representatives to speak about confidential tax matters with designated third parties. Such
 authority is limited to the tax period, tax type and the specific issue/purpose identified herein.
 While tax practitioners are encouraged to maintain appropriate declarations of authority to handle clients' tax matters within their
 own records, tax practitioners should not submit unsolicited REV-677 forms to the department en masse or as a matter.of routine
 Such forms will be disregarded.
 A REV-677 form should only be submitted to an individual within the department upon an agent's request for such authorization.
 If a department representative has requested a REV-677 form to authorize discussion of confidential tax matters with a third party, please return
 the form to the department representative as requested.
 PART I                 Power of AttorneyNOTE: An organization, firm or partnership may not be designated as a taxpayer’s representative.
 The following taxpayer
START Taxpayer Name                                           Identifying Number
Ü
      Address                                                 City                               State ZIP

 hereby appoints
      Appointee Name(s)                                       Telephone NumberPreparer Tax Identification Number (PTIN)

      Address                                                 City                               State ZIP

 as attorney-in-fact to represent the taxpayer before any office of the PA Department of Revenue for the following tax matter(s). Specify the
 type(s) of tax, tax year(s) or period(s), tax return/report at issue and the specific purpose for which authorization to discuss confidential tax
 matters with a third-party is sought.
      Type(s) of taxTax Year(s) or Period(s)Tax Return/Form                                   Purpose for Authorization

 The attorney-in-fact is authorized, subject to revocation, to receive confidential information and perform any and all acts the principal can perform
 with respect to the above-specified tax matters, excluding the power to receive refund checks and the power to sign the return, unless specifically
 granted below.
 Initial here                                     to grant the power to receive – but not to endorse or cash – refund checks for the above-referenced tax matters to
 the appointee named above.
 Only if this form is being submitted to the department in response to an audit, provide an address below to which copies may be sent of notices
 and other written communications addressed to the taxpayer in proceedings involving the above-specified tax matters.
      Appointee Name(s)                                       Telephone Number

      Address                                                 City                               State ZIP

 This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the PA Department of Revenue for the
 same matters and years or periods covered by this power of attorney, except the following:
      Granter Name                                            DateMM/DD/YYYY       Refer to attached copies of
                                                                                   earlier powers and authorizations
      Address                                                 City                               State ZIP

 Signature of or for taxpayer
 If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer, such party certifies he/she has the authority to execute this power
 of attorney on behalf of the taxpayer.
      Signature                                   Title                                          DateMM/DD/YYYY
        PLEASE SIGN AFTER PRINTING.

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If the power of attorney is granted to a person other than an attorney, certified public accountant or enrolled agent, the taxpayer's signature must
be witnessed or notarized below.

The person signing as or for the taxpayer (check and complete one):

is known to and signed in the presence of the two disinterested witnesses whose signatures appear here:
                    PLEASE SIGN AFTER PRINTING.
                             (Signature of Witness)                          (Date)
                                                                  MM/DD/YYYY
                    PLEASE SIGN AFTER PRINTING.
                             (Signature of Witness)                          (Date)
                                                                  MM/DD/YYYY

appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.

Witness             PLEASE SIGN AFTER PRINTING.                              NOTARIAL SEAL
                  (Signature of Notary)             (Date)
                                                    MM/DD/YYYY

PART II           Declaration of Representative
I declare that I am one of the following:
1 a member in good standing of the bar of the highest court of the jurisdiction indicated below;
2 duly qualified to practice as a certified public accountant in the jurisdiction indicated below;
3 a bona fide officer of the taxpayer organization;
4 a full-time employee of the taxpayer;
5 a member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);
6 a fiduciary for the taxpayer; and/or
7 Other (specify)                                                                              ;
and that I am authorized to represent the taxpayer identified in Part I for the tax matters specified therein.

DESIGNATION                  JURISDICTION
(INSERT APPROPRIATE NUMBER                          SIGNATURE(STATE, ETC.)         DATE
FROM ABOVE LIST)                                                             MM/DD/YYYY
                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

                                                  PLEASE SIGN AFTER PRINTING.

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