City of Englewood 

                                   Income Tax Division 

                                   Power of Attorney 
                                                                                                                                                                                      
                                   KNOW ALL MEN BY THESE PRESENT: 
                                                                                      
That I, _________________________ of _____________________________________________ 
     Name of Grantor                                                                             Address of Grantor 
      
County of ______________,State of ____________________, have made, constituted and appointed,  
        County                                                                 State 
      
and by this document, do hereby appoint _________________________________________________  
                                                                                                                       Name of Grantee 
      
of ____________________________ County of __________________, State of ________________, 
     Address of Grantee                                                                      County                                                                            State 
      
(_____)_______________,my true and lawful attorney in fact, for me and in my name and stead. I  
                 Phone Number  
                                                                           
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                                     POWER OF ATTORNEY.  

This POWER OF ATTORNEY is limited for use at the City of Englewood, Income Tax Department for  
 
the tax year(s) ____________ and/or concerning the matter of _______________________________.  
           Tax Year(s)                                                                                                                     Explain Matter for Grantee to Discuss 
 
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