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CDTFA-392 (S1B) REV. 1 5 3 ( -23) STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION
Confidential tax information may be received by the attorney(s)-in-fact (or any of them), subject to revocation, and the
attorney(s)-in-fact (or any of them) may perform on behalf of the taxpayer(s) the following act(s) for the tax or fee matter(s)
described on the previous page (check the box[es] for the power[s] granted):
General authorization (including all acts described below).
Specific authorization (selected acts described below).
To confer and resolve any assessment, claim, or collection of a deficiency or other tax or fee matter pending before the identified
agency and attend any meetings or hearings for the specified law identified above.
To receive, but not to endorse and collect, checks in payment of any refund of taxes, penalties, or interest.
To execute petitions, claims for refund, and/or amendments.
To execute consents extending the statutory period for assessment or determination of taxes.
To delegate authority or to substitute another representative.
Other (specify):
Does this power of attorney revoke all earlier power(s) of attorney on file with CDTFA as identified above for the same matters
and tax years or periods covered by this form (check the box for either yes or no):
Yes
No, this power of attorney does not revoke all earlier power(s) of attorney on file with CDTFA as specified for the following:
(specify to whom power of attorney is granted, date and address, or refer to attached copies of earlier power[s])
NAME DATE POWER OF ATTORNEY GRANTED
ADDRESS (number and street, city, state, and ZIP Code)
Unless limited, this power of attorney will remain in effect until the final resolution of all tax or fee matters specified herein
(specify expiration date if limited term):
TIME LIMIT/EXPIRATION DATE (for CDTFA purposes)
Signature of taxpayer(s):
If a tax or fee matter concerns a joint return, both spouses must sign if joint representation is requested. If you are a corporate officer,
partner, guardian, tax or fee matters partner/person, executor, receiver, registered domestic partner, administrator, or trustee on behalf
of the taxpayer, by signing this power of attorney, you are certifying that you have the authority to execute this form on behalf of that
taxpayer.
IF THIS POWER OF ATTORNEY IS NOT SIGNED AND DATED BY AN AUTHORIZED INDIVIDUAL,
IT WILL BE RETURNED AS INVALID.
SIGNATURE TITLE (if applicable) DATE
PRINT NAME TELEPHONE NUMBER
SIGNATURE TITLE (if applicable) DATE
PRINT NAME TELEPHONE NUMBER
CLEAR PRINT
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