CALCASIEU PARISH SCHOOL BOARD 

                                            SALES & USE TAX DEPARTMENT 
                                  Power of   Attorney and                    Declaration              of Representative                               
                                                                                                                                                         PLEASE TYPE OR PRINT.   
 
State of   ___________________________________________                                    Parish/County   of ___________________________________                            
 
________________________________________________                                          ________________________________________________ 
Your name or   Name of   Entity                                                           Social Security/Louisiana      or   Federal ID   Number          
 
________________________________________________                                          ________________________________________________ 
Spouse’s name, if   joint (or     corporate officer,  partner or                          Spouse’s Social Security     Number     (if     a joint return)     
fiduciary,     if a business )   
                                                                                          Mark one:     
_________________________________________________                                              Original   – your first power    of   attorney authorizing    this act       
Street Address                                                                                 Amend   – changes an    existing   power   of attorney     for       
 
________________________________________________                                          ________________________________________________ 
City/State/ZIP                                                                                                                     (Name) 
                                                                                               Cancel/Revoke–cancels   a previously filed            power   of attorney   for  
 
Expiration Date        ____________________________________                               ___________________________________________________ 
                                   (Month/Day/Year)                                                                                (Name) 
 
I/we appoint the      following   as my/our   true and lawful  agent and     attorney      in fact to represent‐ ‐    me/us before the Calcasieu       Parish                    
School Board Sales/Use        Tax Department.    The  agent  and attorney       in fact‐ ‐ is authorized   to provide   and receive   confidential       and non               ‐
confidential information concerning           my/our  local  sales/use      taxes,    and to perform   any and   all acts   that I/we can perform       with respect             
to my/our       tax matters,  unless noted below.            
 
__________________________________                            ________________________________                                  ______________________________ 
                    Name  #1                                                             Name #2                                                       Name   #3
 
__________________________________                            ________________________________                                  ______________________________ 
                    Name   of Firm                                                      Name   of Firm                                            Name   of Firm   
 
__________________________________                            ________________________________                                  ______________________________ 
                   Street Address                                                       Street Address                                            Street Address    
 
__________________________________                            ________________________________                                  _______________________________ 
                    City/State/ZIP                                                        City/State/ZIP                                          City/State/ZIP 
 
__________________________________                            ________________________________                                  ______________________________ 
                Telephone Number                                                    Telephone Number                                           Telephone Number        
 
__________________________________                            ________________________________                                  _______________________________ 
                    Fax Number                                                           Fax Number                                                  Fax Number    
 
__________________________________                            ________________________________                                  ______________________________ 
                    Email Address                                                      Email Address                                              Email Address      
 
Unless noted, the        agent and attorney   in fact‐ ‐ is authorized   to perform      any and all acts  that you  can perform    with  respect to      your                   
tax matters, including        the authority to sign   tax returns.  If you want       to limit the   agent and attorney     in fact’s authority‐ ‐   to specific                 
tax types, periods,       and/or  duties, you must    indicate the types     of authority      below.            
__________________________________________________________________________________________ 

__________________________________________________________________________________________ 

__________________________________________________________________________________________ 
  

The agent    and  attorney     in‐ ‐ fact does  not have     the power      to: (Mark  only  the  items    below  you       do not    wish to grant.)                   
       Execute agreement to   suspend prescription                of tax.        
       File   a protest to     a proposed assessment.             
       Execute offers in   compromise or   settlement of tax   liability.                    
       Represent the taxpayer       before      the department         in any   proceeding,     including     protest      hearings.            
       Obtain    a private letter ruling   on behalf      of the   taxpayer.         
       Perform other acts.       (Explain.)     _______________________________________________________________________________                                                         
 
The agent and     attorney     in‐ ‐ fact shall be authorized     to receive    copies of notices   and communications                from the Calcasieu      Parish  School             
Board Sales/Use       Tax Department         upon   request.     The taxpayer       will continue  to be mailed the         original  notices    and  written                            
communications. 
 
The filing  of   this Power of Attorney         automatically       revokes     all earlier  Power(s)      of Attorney      on file with the   Calcasieu      Parish School              
Board Sales/Use Tax         Department          for the  same    tax matters    and years    or periods      covered by this document.           If you do not   want to                 
revoke   or cancel the    authority       of an   agent  and attorney       in fact,‐ ‐ mark here                        . You must   attach a copy   of any   Power  of Attorney        
you want     to   remain in   effect. If this   Power    of Attorney     is not signed     and dated      by all parties,     it will be returned.                    
 
By signing   this Power    of   Attorney as a     corporate officer,      partner,  guardian,     tax matters     partner, executor,         receiver, administrator,      or            
trustee on behalf     of   the taxpayer,     I certify   that I have  the   authority  to execute   this form on behalf          of the  taxpayer.    If this matter                     
concerns   a joint return   filed by     a husband and wife,       both must      sign if joint representation    is requested.                        
 
_______________________________________________________________________________                                                                           ____________________ 
Taxpayer Signature                                                                                                                                                    Date 
____________________________________________________________________________                                                                              ____________________ 
Spouse Signature                                                                                                                                                      Date 
_______________________________________________                                           ____________________________                                    ____________________ 
Signature   of duly authorized      representative,          if the   taxpayer                       Title                                                            Date 
Is   a corporation, partnership,      executor      or administrator              
 
Under penalties of   perjury, I declare          that:         
•      I am not currently   under   suspension       or disbarment          from  practice   before  the Internal          Revenue    Service or the Louisiana   State   Bar             
       Association. 
•      I am one of   the following:        
       a.   Attorney     – a member in   good standing           in the   jurisdiction licensed   to practice.                  
       b.   Certified Public Accountant            –   duly qualified    to practice   as a certified     public accountant.                
       c.   Enrolled Agent       –     a person enrolled    to practice     before  the Internal  Revenue        Service.              
       d.   Officer     – a bona fide officer   of the   taxpayer     organization.           
       e.   Employee     – an employee of   the taxpayer.                  
       f.   Family Member –     a member of the   taxpayer’s              immediate       family (state the      relationship,   i.e., spouse,   parent,      child, brother,            
            or sister) __________________________________________.                                  
       g.   Other (state the     relationship,      i.e., bookkeeper        or friend)   ____________________________________.                                  
 
            Designation-Insert                   Jurisdiction and Enrollment/ Bar                                                                      
         Applicable Letter (a.-g.)                 Number, if applicable                                         Signature                                            Date 
                                                                                                                                                       
Thus Sworn      to   and Subscribed       Before    Me, Notary,       in the   presence   of the undersigned      two witnesses,          who personally       came   and                
appeared, on this       ___________        day   of _______________________________,                         20______.            
 
______________________________________                                       _____________________________________________________________ 
            Signature   of Witness                                                                                               Notary 
 
______________________________________                                       _____________________________________________________________ 
            Print Witness Name                                                                       Print name of   Notary and          Notary  Number          
 
______________________________________ 
            Signature   of Witness         
 
______________________________________ 
            Print Witness Name                                                                                                                                        F024 11/2009