TBOR 1  
                                                                                                                                                   Rev. 07/18  
Ohio I                 ~ae:;~~ent of                             11111111111111111     1111111 
                       P.O. Box 1090                                       16310102  
                       Columbus, OH 43216-1090  

                                            Declaration of Tax Representative 
   Part 1: Taxpayer Information 
                                            I 
  Taxpayer’s name                                                                                               
   Taxpayer’s name                                                                                              
   Business Name (if applicable)  
   
   Address  
  City                                                                               State                            ZIP code  
  FEIN  
   (Only use SSN if authorizing individual income tax representative or if business does not have a FEIN.) 
     Part 2: Representative InformationPlease-                   indicate if more than one representative in the space below. 
                                                                                                                                             I 
 Representative’s name  
 Representative’s firm         (if applicable)      
 Address 
 City                                                                                State                            ZIP code 
 Telephone number                                                                 Fax number  

 E-mail address 

   Part 3: Taxpayer Signature             I 
   The taxpayer identified above authorizes the representative identified    above to represent the taxpayer before the Department of Taxation. This autho-
   rization includes the authority to view and receive copies of returns, reports or other documents filed   by the taxpayer or prepared by the Department 
   of Taxation concerning the business, property or transactions of the taxpayer, request alternative methods of taxation, present evidence or legal argu-
   ments to any employee of the Department of Taxation, raise objections to audit    findings or assessments, file petitions or applications and waive statutes 
   of limitation. This authorization does not authorize the tax representative to sign any form or declaration where the Ohio Revised Code specifically 
   requires that the form or declaration be signed by the taxpayer.      The taxpayer understands that the acts of the authorized representative may 
   increase or decrease the taxpayer’s tax liabilities and legal rights. The taxpayer must indicate all tax matters subject to this authorization 
   and all restrictions, if any, in the space on the following page. Note:  Unless the authorized representative is licensed to practice law, the 
   representative may not sign Voluntary Disclosure Agreements, Settlement Agreements, or similar binding Agreements with the Department 
   of Taxation, on behalf of the taxpayer. 
   I certify, under penalties of perjury, that I am the taxpayer or that I am a corporate officer,  LLC member, general partner, guardian, tax manager or 
   similar employee authorized to act on tax matters, executor, receiver, administrator or trustee on behalf of the taxpayer and that I have the authority to 
   execute this form on behalf of the taxpayer. If this form is not properly completed, this Declaration of Tax Representative will not be processed. 
   Signature                                                                                                          Date 

   Name (print)                                                                  Title 

   Telephone number                                                              E-mail 

   Spouse’ssignature      (required for joint income tax lingfi        )                                               Date  

 Tax Matters                     Check box if “all tax matters” for tax period  
                    I    D 
 Tax type                                                                  Ohio account no.                           Tax period  

 Tax type                                                                  Ohio account no.                           Tax period  

 Tax type                                                                  Ohio account no.                           Tax period  

 Tax type                                                                  Ohio account no.                           Tax period  

                                                                                                                          TBOR 1  
             Depa!'1ment of                                                                                               Rev. 07/18  
Ohio I Taxation 
                                                  IIII I Ill 1111111111111111 
             P.O. Box 1090                                  16310202  
             Columbus, OH 43216-1090  

Restrictions to this Declaration       I The following restrictions are placed on this Declaration of Tax Representative:  

Expiration Date IThis declaration is valid until                            (please indicate no more than     three years). If no 
expiration date is given, this declaration will continue to completion of any matter currently under consideration by the 
department, unless specifically revoked by the filing   of a subsequent declaration for the same tax period(s)/matter(s).      As 
applied to a new tax period/matter, the declaration will expire one year after the date that it is signed.  
Declaration of Representative   Under penalties of perjury, I declare that:  
                                  • I am not currently under suspension or disbarment from practice within the state of 
                                         Ohio or any other jurisdiction;  
                                  • I am aware of the regulations governing my practice in Ohio and the penalties for 
                                         false or fraudulent statements provided;  
                                  • I am authorized to represent in Ohio the taxpayer(s) identified     for the tax matter(s) 
                                         specified herein; and I am one of the following (please indicate by checking the 
                                         box beside the appropiate number): 
                                         1. Attorney – a member in good standing of the bar of the highest court of the 
                                           jurisdiction shown below.  
                                         2. Certified public accountant or public accountant – duly qualified   practice in the 
                                n 
                                            jurisdiction shown below.  
                                         3. Enrolled agent – enrolled as an agent under the requirements of the IRS.  
                                         4. Offi  cer – a bona fide officer  of the taxpayer’s organization.  
                                         5. Full-time employee – a full-time employee of the taxpayer.  
                                         6. Family member – a member of the taxpayer’s immediate family (check appro-
                                ~           priate response:     spouse,       parent,    child,   brother or  sister).  
                                         7.Other – provide explanation                                     
                                 

Designation (insert number 1 - 7)        Ohio License Number                        Signature                          Date     

 *Mail: P.O. Box 1090, Columbus, OH 43216-1090            I  E-mail: TBOR1@tax.state.oh.us         I   Fax: (206) 888-4377
                                                                                                                *Most secure method
                                         (Use the same method to revoke declaration.)