City of Kansas City, Missouri - Revenue Division
     RD-PA                        POWER OF ATTORNEY
FORM 12/12                         

                                  Phone: (816) 513-1120
                                  Fax:    (816) 513-1075
                                  E-file: www.kcmo.org/revenue
PLEASE TYPE OR PRINT
TAXPAYER(S) NAME / BUSINESS NAME                                                  SOCIAL SECURITY NO.

NUMBER AND STREET                                                                 FEDERAL I.D. NUMBER

CITY OR TOWN, STATE, ZIP CODE                                                     EMPLOYER WITHHOLDING NO.

HEREBY APPOINTS
NAME OF APPOINTEE                         ADDRESS

NAME OF APPOINTEE                         ADDRESS

NAME OF APPOINTEE                         ADDRESS

NAME OF APPOINTEE                         ADDRESS

as attorney(s)-in-fact to represent taxpayer(s) before the City of Kansas City, Missouri, Finance Department, Revenue Division, with 
respect to the following tax matter(s) (the tax type(s), form(s) and year(s) to which this form applies must be listed below:
                  TYPE OF TAX                           TAX FORM NUMBER           YEAR(S) OR PERIOD(S)
     (EARNINGS TAX, EMPLOYER WITHHOLDING,               (RD-105, RD-108, ETC.)
           BUSINESS LICENSE, ETC.)

The attorney(s)-in-fact (or any of them) are authorized, subject to revocation, to receive confidential information and perform any and 
all acts that the taxpayer(s) can perform with respect to the above specified tax matters, but not the power to endorse or receive 
checks in payment of any refunds, nor to sign return(s).

By execution of this power of attorney, all earlier powers of attorney on file with the Kansas City, Missouri, Finance Department, 
Revenue Division, for the same tax matter and years or periods covered by this power of attorney are revoked, except the following 
(specify to whom power of attorney was granted, date and address, or refer to attached copies of earlier powers of attorney and 
authorizations.):

                                                                                                                             Page 1 of 2

                                City of Kansas City, Missouri - Revenue Division
     RD-PA                      POWER OF ATTORNEY
FORM 12/12                       

                                Phone: (816) 513-1120
                                Fax:    (816) 513-1075
                                E-file: www.kcmo.org/revenue

SIGNATURE OF OR FOR TAXPAYER(S)

I (we) hereby certify that I (we) am (are) the taxpayer(s) named herein or that I (we) have the authority to execute this power of attorney 
on behalf of the taxpayer(s).
NAME                                                                                                    TITLE (IF APPLICABLE)

SIGNATURE                                                                                               DATE

NAME                                                                                                    TITLE (IF APPLICABLE)

SIGNATURE                                                                                               DATE

                                        DECLARATION OF REPRESENTATIVE

I declare that I am aware of Regulation 12 CSR 10-41.030 and 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. officer of the taxpayer organization;
4. a full-time employee of the taxpayer;
5. a fiduciary for the taxpayer;
6. enrolled agent;
7. other ______________________________________________________________________
and that I am authorized to represent the taxpayer identified above for the tax matters there specified.

     DESIGNATION                        JURISDICTION           SIGNATURE                                                     DATE
(INSERT APPROPRIATE NUMBER FROM         (STATE, ETC.)
           ABOVE LIST)

                                                                                                                             Page 2 of 2

PLEASE SEND COMPLETED FORM(S) TO:
                                        Revenue Division
                                        City Hall, Second Floor
                                        414 E. 12th St.
                                        Kansas City, MO 64106