POWER OF ATTORNEY  

                                                                                                 AND 
                                                                   DECLARATION OF REPRESENTATION 
                          
  Form 21-002-13 
 
PART I  POWER OF ATTORNEY 
Taxpayer(s) Information                                                                          For DOR Use Only 
Taxpayer Name(s) and Mailing Address                            Taxpayer Social Security Number 
                                                                                                 Received by:  
                                                                 
                                                                Spouse Social Security Number    Name __________________________ 
                                                                 
                                                                                                 Phone _________________________ 
                                                                Federal ID Number (FEIN) 
                                                                                                 Date   ____________________ 
                                                                 
Hereby appoint(s) the following representative(s): 
Representative Information 
Name and Mailing Address                                            
                                                                   Phone Number        (     )  _________________________________________________   
 
                                                                   FAX Number           (      )    _________________________________________________ 
Name and Mailing Address                                            
                                                                   Phone Number        (     )     ________________________________________________   
 
                                                                   FAX Number            (     )   _________________________________________________ 
Name and Mailing Address                                            
                                                                   Phone Number         (     )    _________________________________________________   
 
                                                                   FAX Number             (     )   _________________________________________________ 
  
To represent the taxpayer(s) before the Mississippi Department of Revenue in: 
Tax Matter(s)  
  Tax Type (Income, Franchise, Sales, Insurance Premium, etc.)      Account Number                     Tax Period(s) 
                                                                  
Acts Authorized 
I (we) as the taxpayer(s) give authorization to the representative(s) to receive and inspect confidential tax information and 
to perform any and all acts that the taxpayer(s) can perform with respect to the matters concerning the taxes and 
accounts described under Tax Matter(s) above, for example, the authority to sign any agreements, consents or other 
documents and to represent the taxpayer(s) in any informal or formal proceeding involving the Department of Revenue.  
The authority of the representative(s) does not and cannot include the power to substitute another representative or to 
request that tax return(s) or other confidential tax information of the taxpayer(s) be inspected by or disclosed to another 
person.    The  authority  also does not include the authority  to receive tax refund checks or to sign returns unless 
specifically added below.    
 
List any specific additions or deletions to the acts otherwise authorized by this Power of Attorney:   
 
Additions:  ____________________________________________________________________________________ 
 
Deletions:  ____________________________________________________________________________________ 
 
The Department of Revenue may reject a submission due to incompleteness, lack of specificity, or inappropriateness.  
 
DEPARTMENT OF REVENUE                      P.O. BOX 1033                     JACKSON, MS  39215-1033                        Phone: 601-923-7000 
 

DOR Power of Attorney,  Form 21-002 
 
Retention/Revocation of Prior Power(s) of Attorney 
The filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Department of 
Revenue for the same tax matter(s) covered by this document.  If you do not want to revoke a prior Power or Attorney,  
check here    and ATTACH A COPY OF THE POWER(S) OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.   
 
Who Must Sign and What Documentation of Authority Must Be Attached 
If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested.  A corporation 
or subsidiary MUST contain the signatures of a principal officer and the secretary or other officer.  A guardian, executor, 
receiver, administrator, conservator or trustee MUST attach the appropriate documentation granting the authority from the 
court or taxpayer. 
 
Signing is Certification Under Oath Subject to Penalty of Perjury 
The person(s) signing this Power  of  Attorney  and  Declaration of Representations certifies under oath that all the 
information  contained  in this document is true and correct  and that he, she or they have the authority to sign this 
document as the taxpayer(s) or on behalf of the taxpayer(s) and acknowledge that this Power of Attorney and Declaration 
of Representation is being signed under the penalty of perjury pursuant to Miss. Code Ann. § 27-3-83(5). 
 
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED. 
 
                                Signature                                           Date                 Title (if applicable) 
                                     
                                Print Name                                          Phone Number                   FAX Number 
                                     
                                Signature                                           Date                 Title (if applicable) 
                                     
                                Print Name                                          Phone Number                   FAX Number 

PART II  DECLARATION OF REPRESENTATIVE
 
Under penalties of perjury and Miss. Code Ann. §97-7-10, I declare that: 
1)  I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there: and   
2)  I am one of the following: 
      a.  Attorney – a member in good standing of the bar of the highest court of the jurisdiction shown below. 
      b.  Certified Public Accountant – duly authorized to practice as a certified public accountant in the jurisdiction shown. 
      c.  Officer – a bona fide officer of the taxpayer’s organization. 
      d.  Full-time employee – a full time employee of the taxpayer. 
      e.  Family Member – a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister). 
      f.   Enrolled Agent – enrolled as an agent under the requirements of the IRS. 
      g.  Other – Provide explanation ________________________________________________________________ 
 
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED. 
 
Designation – Insert State Issuing         State License                 Signature                                 Date
 Above letter (a-g)  License               Number 
                                                                                                          
DEPARTMENT OF REVENUE                      P.O. BOX 1033                     JACKSON, MS  39215-1033                        Phone: 601-923-7000