R-7006 (1/11)

                                                  Power of Attorney and Declaration of Representative

PART I. POWER OF ATTORNEY
Taxpayer(s) must sign and date this form on page 2.                                                        PLEASE TYPE OR PRINT.
 Your Name or Name of Entity                                   Spouse’s Name, if a joint return (or corporate officer, partner or fiduciary, if a business)

 Street Address                                                City                                        State             ZIP

 Social Security/Louisiana or Federal ID Number                        Spouse’s Social Security Number (if a joint return)

I/we appoint the following representative as my/our true and lawful agent and attorney-in-fact to represent me/us before the Louisiana Department of 
Revenue. The representative is authorized to receive and inspect confidential information concerning my/our tax matters, and to perform any and all acts 
that I/we can perform with respect to my/our tax matters, unless noted below. Modes of communication for requesting and receiving information 
may include telephone, e-mail, or fax. The authority does not include the power to receive refund checks, the power to substitute another rep-
resentative, the power to add additional representatives, or the power to execute a request for disclosure of tax returns or return information 
to a third party. 
Representative must sign and date this form on page 2, Part II.
 Name

 Firm

 Street Address

 City                                                                                                      State          ZIP

 Telephone Number
 ( )
 Fax number
 ( )
 E-mail Address

Acts Authorized.  Mark only the boxes that apply. By marking the boxes, you authorize the representative to perform any and all acts on your behalf, 
including the authority to sign tax returns, with respect only to the indicated tax matters:

      Tax Type                                  Year(s) or Period(s)          Tax Type                     Year(s) or Period(s)
■ Individual income tax                                                       ■ Sales and use tax          
■ Corporate income/franchise tax                                              ■ Withholding tax            
■ Special Fuels tax                                                           ■ Gasoline tax               
■ Tobacco tax                                                                 ■ Other (Please specify.)    

DELETIONS. Mark or list any specific deletions to the acts otherwise authorized in this power of attorney.
■	Sign the return(s) for the above tax matters.
■ Execute an agreement to suspend prescription of tax.
■ File a protest to a proposed assessment.
■ Execute offers in compromise or settlements 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.
■ Other prohibited acts. (List prohibited acts.)  _____________________________________________________________________________________________________________

R-7006 (1/11)                                                                                                                                     Page 2

NOTICES AND COMMUNICATIONS. Original notices and other written communications will be sent only to you, the taxpayer. Your representative may request 
and receive information by telephone, e-mail or fax. Upon request, the representative may be provided with a copy of a notice or communication sent to you. If 
you want the representative to request and receive a copy of notices and communications sent to you, check this box. ■

REVOCATION OF PRIOR POWER(S) OF ATTORNEY. Except for Power(s) of Attorney and Declaration of Representative(s) filed on Form R-7006 (1/11), the 
filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Louisiana Department of Revenue for the same tax matters 
and years or periods covered by this document.

Signature of Taxpayer(s). If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested. If signed by 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 POWER OF ATTORNEY IS NOT SIGNED AND DATED, IT WILL BE RETURNED.
_______________________________________________________________________________________________________________________________________  ______________________________
  Taxpayer signature                                                                                                                     Date (mm/dd/yyyy)

____________________________________________________________________________________________________________________________________________   _________________________________
  Spouse signature                                                                                                                       Date (mm/dd/yyyy)

_________________________________________________________________________________    _______________________________________________________   _________________________________
 Signature of duly authorized representative, if the taxpayer                      Title                                                 Date (mm/dd/yyyy) 
 is a corporation, partnership, executor or administrator

Part II. DECLARATION OF REPRESENTATIVE
Under penalties of perjury, I declare that:
 I am not currently under suspension or disbarment from practice before the Internal Revenue Service.
 I am authorized to represent the taxpayer(s) identified in Part I for the tax matters specified there; and
 I am one of the following: (insert applicable letter in table below)
   a. Attorney—a  member in good standing of the highest court of the jurisdiction shown below.
   b. Certified Public Accountant—duly qualified to practice as a certified public accountant in the jurisdiction shown below.
   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)
   h. Former Louisiana Department of Revenue Employee. As a representative, I cannot accept representation in a matter with which I had 
   direct involvement while I was a public employee.  

IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL BE RETURNED.

   Designation-Insert       State Issuing                     State License Number                   Signature                                Date
   Above Letter (a-h)       License                                                                                                      (mm/dd/yyyy)