City of Columbus 

                                         Income Tax Division 

                       Limited Power of Attorney

                                                                   BE IT KNOWN:

     That I,                                                              of
                         Name of Grantor                                                    Address

     County of                                                    , State of                                                            ,  have   made,
                         County                                                             State

     constituted and appointed, and by this document, do hereby appoint 
                                                                                                   Name of Grantee

     of                                                                     County of                                      ,
                               Address                                                                     County

     State of                                                   ,                           ,  my true  and lawful  attorney in fact, 
                         State                                              Phone Number
     for me and in my name and stead. I hereby grant unto my said attorney full power and authority to do and 
     perform any and every act and thing that I might or could do, if personally present. I hereby ratify and 
     confirm all that my said attorney shall lawfully do or cause to be done by virtue of this limitd POWER OF 
     ATTORNEY.

     This POWER  OF  ATTORNEY  is  limited  for  use  at  the  City  of  Columbus,  Income  Tax  Division.  I 
     understand that the grantee may be permitted to view my tax record, including filings and income received, 
     and I further understand that the grantee may sign agreements and or admit liability on my behalf. Only the 
     person named in the POWER OF ATTORNEY,                                 after proper identification, shall have the authority given 
     by this document. 

     IN WITNESS WHEREOF, I have hereto set my hand this                    day of                                                 , 
                                                                                        Day                           Month

        Year

                                                                                            Name of Grantor

     Be it remembered that the above-named person personally appeared before me, a ( notary / attorney ) in and 
     for said County, and acknowledged that ( he / she ) did sign the foregoing instrument and that the same is 
     ( his / her ) voluntary act and deed. In witness whereof, I have subscribed my name and official seal, this      
                   day of                                     , 
     Day                 Month                                    Year

                                                                                            Signature of Notary Public
Rev. 12/1/2021