City of Cincinnati 

                                                                                        Income Tax Division 
                                                                                       
                               KNOW ALL MEN BY THESE PRESENT: 
  
 That I, ________________________________ of __________________________________ County of 
                           (Name of Grantor)                                                                          (Address) 
  
 _____________________, State of ____________________, have made, constituted and appointed, and by 
                (Name of County)                                      (Name of State) 
  
 this document, do hereby appoint ________________________________ of __________________________, 
                                                       (Grantee)                                                                    (Address) 
  
 County of _____________________, State of _____________________, my true and lawful attorney in fact, 
                     (Name of County)                                             (Name of State) 
  
 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 POWER OF ATTORNEY.   
  
 This POWER OF ATTORNEY is limited for use at the City of Cincinnati Income Tax Bureau.  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 hereunto set my hand this __________ day of ________________, ______. 
                                                                                                                                            (day)                             (month)                   (year) 
  
                                                                                                         ______________________________ 
                                                                                                  Signature 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  
                                                                                                                           (day) 
 of _________________,          ________            _.
                      (month)         (ye ar)
                                                  
                                                                          ______________________________ 
                                                                      Signature of Notary Public