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TENNESSEE DEPARTMENT OF REVENUE
Installment  Payment  Agreement  Program

                               TENNESSEE DEPARTMENT

                                        OF REVENUE

                                                

                       INSTALLMENT PAYMENT AGREEMENT
                                        APPLICATION

                                        The Following Pages Contain:

                              Basic Information
                              Terms and Conditions
                              Installment Payment Application
                              Statement of Financial Condition for Individuals
                              Statement of Financial Condition for Businesses
                              Supporting Document Checklist
                              Financial Release Statement
                              Power of Attorney

RV-F0200201 (Rev. 7-16)

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Tennessee Department of Revenue
   Installment Payment Agreement
  Program

                       TENNESSEE DEPARTMENT OF REVENUE

                                BASIC INFORMATION CONCERNING
                       INSTALLMENT PAYMENT AGREEMENT APPLICATIONS

 The Installment Payment Application is to be submitted only on Form App-1, and must include the required financial disclo-
  sure form(s) and other supporting documentation outlined on the form, Supporting Document Checklist, (found in this book-
  let).  A copy of Form APP-1 may be used provided no changes have been made to the form.  Depending upon the legal
  structure of the applicant, the following Statement of Financial Condition forms are required:

                                Legal Structure   Form(s) Required
                                Individual        IPA-IND
                                Proprietorship    IPA-IND & IPA-BUS
                                Partnership       IPA-IND & IPA-BUS
                                Corporation       IPA-BUS
                                Trust/Estate      IPA-BUS
                                Corporate Officer IPA-IND

  Individual applicants must submit Form IPA-IND, Financial Condition Statement for Individuals.  Self-employed applicants
  must also submit Form IPA-BUS, Financial Condition Statement for Business.  Corporations and Partnerships must submit
  Form IPA-BUS.  Financial Condition Statement for Individuals may also be required of corporate officers or business partners.
  Applicants may obtain the Installment Payment Agreement booklet at any of the seven regional offices listed on the back
  page of this booklet.

 The statement of Financial Condition For Individuals and Businesses, (IPA-IND and IPA-BUS), provides the Tennessee
  Department of Revenue (the Department) with credit and financial information that will be utilized in an evaluation of the
  Financial Condition of an individual and/or business entity.  Every item of the financial statement must be completed and
  should reflect accurate statements and amounts.  If an item is not applicable to you, insert “NA”.  An incomplete Statement
  of Financial Condition and/or unsigned by the applicant in the areas required, will not be considered.

 In all cases whereby the Statement of Financial Condition For Individuals are completed, the Financial Release Statement,
  Form RV-F0200501, (found in this booklet), must also be completed by the individual or business entity and endorsed by a
  Notary Public.

 If the Installment Payment Agreement Application or other forms are to be completed and/or signed by someone other than
  the liable parties, then Form RV-F0103801 Power of Attorney, (found in this booklet) must be completed.

 Installment Payment Agreements are submitted under the provisions of an inability to pay a tax in full and will require an
  analysis of your financial condition or in some instances, both.  In all cases the form, Supporting Document Checklist, (found
  in this booklet), must be completed.

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 Tennessee Department of Revenue
      Installment Payment Agreement
      Program

             TENNESSEE DEPARTMENT OF REVENUE

                                   

                                   INSTALLMENT  PAYMENT AGREEMENT
                                   TERMS & CONDITIONS

 I understand that by endorsing the Installment Payment Agreement that pursuant to T.C.A. § 67-1-1429 et.
  seq., any rights or defenses are hereby expressly waived for a  period of six (6) years from the date of this
  agreement.

 I understand a condition of this agreement is that daily records of the active business(s) must be kept
  current and that tax reports and payments are made to the Tennessee Department of Revenue in a timely
  manner prescribed by the Department of Revenue.

 I understand that pursuant to the provisions of T.C.A. § 67-1-1401 at.seq., the Tennessee Department of
  Revenue will file lien(s) on the taxpayer(s), business entity and any personal guarantor(s) of the Install-
  ment Payment Agreement.

 I understand that if any payment is not paid when due, or if the taxpayer(s), business entity or other
  personal guarantor(s) of the agreement violates any provisions of the agreement, then, at the Department’s
  option, the entire remaining amount owed as shown, together with any additional penalty or interest may
  become immediately payable and due the Tennessee Department of Revenue.

 I understand and agree that I and any other endorsers of the agreement shall be subject to all terms and
  conditions set out in the stated agreement and that I will be held jointly and severally liable for such debt.

             APPLICANT’S SIGNATURE                               DATE

             APPLICANT’S SIGNATURE                               DATE

            POWER OF ATTORNEY SIGNATURE                          DATE

             (Must complete Power of Attorney - Use Only Department of Revenue Form RV-F0103801, enclosed)

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APP-1                                                                                                                Page 1

                            Tennessee Department of Revenue
                            Installment Payment Agreement Application

1.  Applicant(s) Name and Street Address                           SS #

                                                                   SS #

                                                                   FEI #

                                                                   County

                                                                   Daytime Phone #   (       )
2.  Applicant(s) Mailing Address (If different from above)         3.  Applicant(s) Legal Structure
                                                                   [    ] Individual               [    ] Proprietorship
                                                                   [    ] Partnership              [    ] Corporation
                                                                   [    ] Trust/Estate [    ] Corp. Officer(s)

4. Description of Tax Liabilities To Be Placed on Payment Agreement

      Tax Type                           Account Number                                 Period(s)

[    ] Individual Income Tax

[    ] Sales & Use Tax

[    ] Corporate Income Tax

[    ] Other (Specify)

5. If you are represented by an attorney, accountant or agent, please provide the following contact information:

Name

Firm

Mailing Address

                                                                   Phone Number  (     )

      (Must complete Power of Attorney - Use Only Department of Revenue Form RV-F0103801, enclosed)

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APP-1                                                                               Page 2

6. Summary Statement Supporting Reason For Installment Pay Agreement, (required)

I/WE HAVE EXAMINED THIS INFORMATION, INCLUDING THE ACCOMPANYING SCHEDULES AND STATEMENTS,
AND HEREBY AFFIRM THAT TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF IT IS TRUE, CORRECT AND
COMPLETE.

                       APPLICANT’S SIGNATURE                                    DATE

                       APPLICANT’S SIGNATURE                                    DATE

         POWER OF ATTORNEY SIGNATURE                                            DATE

NOTE:  Department Forms IPA-IND (Statement of Financial Condition for Individuals) and/or IPA-BUS (Statement of Finan-
cial Condition for Businesses) must be completed, signed and attached in order for the application to be complete.  Depart-
ment personnel may request additional verification of the financial information provided on these forms and may request
additional information.

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IPA-IND Page 1
State of Tennessee STATEMENT OF FINANCIAL CONDITION (If additional space is needed,
Department of Revenue attach separate sheet)
FOR INDIVIDUALS

The information requested in this statement should include all household income and expense.
Spouse and dependent information are required although only one person may be liable for the tax.
SECTION I - PERSONAL INFORMATION
1. Taxpayer’s Name(s) and Residence Address 2. Daytime Phone Number 3. Marital Status (Check One)
[ ] Single [ ] Married
[ ] Separated [ ] Divorced

4. Social Security Number 5. Date of Birth
Taxpayer Taxpayer
A. A.
Spouse Spouse
County ( ) Do you own [ ] or rent [ ]? B. B.
6. Previous Address If At Current Address Less Than 2 Years 7. Income Tax Return Information

A. Year of Last Filed Federal Income Tax Return ________
B. Federal Adjusted Gross Income From Last Return $________
C. Year of Last Filed Tennessee Income Tax Return ________

SECTION II - EMPLOYMENT INFORMATION
8. Taxpayer’s Employer or Business - Name and Address 9. Employer Phone Number 10. Occupation

11. Length of Employment 12. Work Relationship

[ ] Employee [ ] Proprietor
Years Mo. [ ] Partner [ ] Officer

13. Spouse’s Employer or Business - Name and Address 14. Employer Phone Number 15. Occupation

16. Length of Employment 17. Work Relationship

[ ] Employee [ ] Proprietor
Years Mo. [ ] Partner [ ] Officer

18. Taxpayer’s Part-time or Previous Employment in Last Three Years19. Spouse’s Part-time or Previous Employment in Last Three Years
Employer’s Name Employment Dates Employer’s Name Employment Dates

To To

To To
To To
20. Taxpayer’s Part-time or Previous Employment in Last Three Years? Taxpayer [ ] Yes [ ] No
Spouse [ ] Yes [ ] No
SECTION III - DEPENDENT INFORMATION
21. Dependent Name (Other Than Spouse) Date of Birth Relationship Monthly Income

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IPA-IND                                                                                                                           Page 2

                                         SECTION IV - ASSETS
22. Cash                                                                           TOTAL (Enter also on Page 3, Item 30-A) $

23. Bank or Credit Union Accounts (Checking, Savings, Certificate of Deposit, etc.)
                 Name of Institution         Account Number                                       Type of Account           Balance
                                                                                                                           $

                                                                                   TOTAL (Enter also on Page 3, Item 30-B) $

24. Bank Credit Cards (i.e., Visa, Mastercard, Discover, American Express, etc.)
                                                                                    Credit                  Amount
                                                                                                                            Available
                 Name of Issuer              Account Number                         Limit                   Owed            Credit
                                                                                                                           $

                                                                                   TOTAL (Enter also on Page 3, Item 30-C) $

25. Securities (Stocks, Bonds, Mutual Funds, IRA, Government Securities, Money Market Funds, etc.)
                                                                                                            Quantity or     Current
         Type                                        Issuer                                                 Denomination    Value
                                                                                                                           $

                                                                                   TOTAL (Enter also on Page 3, Item 30-D) $

26. Real Property (Personal Residence, Vacation or Second Home, Investment Property, Unimproved Land, etc.)
                                         Address                                    Current Market          Amount          Equity In
        Description                                                                 Value                   Owed            Property
                                                                                                                           $

                                                                                   TOTAL (Enter also on Page 3, Item 30-E) $

27. Vehicles - Excluding Leased Vehicles (Including Motorhomes, Campers, Motorcycles, Boats, Trailers, etc.)
                                                                                Tag Current Market          Amount          Equity In
        Description              Make  Model Year           Number                  Value                   Owed            Vehicle
                                                                                                                           $

                                                                                   TOTAL (Enter also on Page 3, Item 30-F) $

28. Other Assets
                                             Current                                                                        Current
                                       Appraised Value                                                                     Appraised Value
Notes Receivable                       $               Timber, Mineral or Drilling Rights                                  $
Cash Surrender Value of Life Insurance                 Patents or Copyrights
Judgments or Settlements Receivable                    Other (Specify)
Vested Retirement Account
Collectables, Antiques or Artwork
                                                                                   TOTAL (Enter also on Page 3, Item 30-G) $

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IPA-IND Page 3

SECTION V - LIABILITIES

29. Liabilities (Do Not Include Any Mortgages or Vehicle Loans)
Total Amount Total Amount
Description Owed Description Owed
Notes Payable $ Past Due Other Taxes $
Installment or Personal Loans Vehicle Leases
Education or Student Loans Other Liabilities:
Bank Revolving Credit
Judgments Payable
Past Due Federal Taxes
Past Due State Taxes
TOTAL (Enter also on Page 3, Item 31) $

SECTION VI - NET WORTH CALCULATION

30. ASSETS
A. Cash $
B. Bank or Credit Union Accounts
C. Bank Credit Cards
D. Securities
E. Real Property
F. Vehicles
G. Other Assets
Total Assets $
31. LIABILITIES $
32. Net Worth (“Total Assets” Minus “Liabilities”) $

SECTION VII - OTHER INFORMATION

33. Have you disposed of any assets or property by sale, transfer, exchange, gift, or in any other manner during the past 18 months?
[ ] Yes [ ] No If “Yes”, identify:

34. Is a foreclosure proceeding pending on any real estate that you own or have an interest in?
[ ] Yes [ ] No

35. Is anyone holding any assets on your behalf?
[ ] Yes [ ] No If “Yes”, identify: Relationship:

36. Are you a party to any lawsuit now pending?
[ ] Yes [ ] No

37. Are you or any business that you own currently under bankruptcy court jurisdiction?
[ ] Yes [ ] No Bankruptcy Case No.:

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IPA-IND                                                                                                                   Page 4
                                         SECTION VIII - INCOME & EXPENSE ANALYSIS

38. Monthly Household Disposable Income
                        Gross Monthly Income                                         Monthly Living Expenses
                Source                   Taxpayer   Spouse                       Source                             Amount
Salary, Wages, Commissions, Tips       $          $        House or Rent Payment                                   $
Self-Employment Income                                     Income Taxes (Federal, State, FICA)
Pensions, Disability & Social Security                     Estimated Tax (If Applicable)
Dividends & Interest                                       Groceries
Gift or Loan Proceeds                                      Medical Expenses & Prescriptions
Rental Income                                              Utilities:
Estate, Trust & Royalty Income                             Electric+$            +Gas $
Workers’ Comp. & Unemployment                              Water $               + Phone $                        =
Alimony & Child Support                                    Insurance:
Other (Specify)                                            Life      $           + Health $                       +
                                                           Auto      $           + Home    $                      =
                                                           Court Ordered Payment
                                                           Personal Loan Payment
                                                           Religious & Charitable Donations
                                                           Clothing & Personal Grooming
                                                           Entertainment & Recreation
                                                           Legal Fees
                                                           Transportation Expense
                                                           Vehicle Loan Payment
                                                           Vehicle Lease Payment
                                                           Property & Ad Valorem Taxes
                                                           Child Care
                                                           Installment & Credit Card Payments
                                                           Tuition Payment
                                                           Other (Specify)

                        Subtotal $                $
                      Combined Monthly Income     $                       Total Monthly Living Expenses            $
39. Net Monthly Household Disposable Income (“Combined Monthly Income” Minus “Total Monthly Living Expenses”)      $

I/we have examined this Statement of Financial Condition for Individuals and hereby affirm that to the best of my/our knowledge and belief, it is true,
correct and complete.

Taxpayer’s Signature                                                      Date

Taxpayer’s Signature                                                      Date

POA Signature                                                             Date

                     (Must complete Power of Attorney - Use Only Department of Revenue Form RV-F0103801, enclosed)

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IPA-BUS                                                                                                                              Page 1
State of Tennessee                         STATEMENT OF FINANCIAL CONDITION                                    (If additional space is needed,
Department of Revenue                                         FOR BUSINESSES                                   attach separate sheet)

                                           SECTION I - BUSINESS IDENTIFICATION
1. Business Name and Address                                             2. Mailing Address (If Different From Street Address)

County
3. Type of Business                                                      4. Daytime Phone Number               5. Number of Employees

6. Type of Ownership                                                     7. Tennessee Entity ID:
[   ]  Proprietorship    [   ]  Partnership
[   ]  Corporation       [   ]  Other (Specify)
8. Beginning Date of Business                                            9. Ending Date of Business (If Closed)

10. Last Franchise Excise Return Filed                        Form       Tax Year Ended         Net Income
                                                                                                $
11. Information About Owner, Partners, Officers, Major Shareholders, etc.
                    Name                       Social Security             Title            Effective          Monthly         Total Shares
                                                              Number                            Date  Salary or Wages          or Interest

                                                                                                      $

                                                              SECTION II - ASSETS
12. Cash On Hand                                                                     TOTAL (Enter also on Page 3, Item 24-A)  $

13. Bank Accounts (General Operating, Payroll, Savings, Certificate of Deposit, etc.)
        Name of Institution                    Account Number                               Type of Account                    Balance

                                                                                                                              $

                                                                                     TOTAL (Enter also on Page 3, Item 24-B)  $
14. Bank Credit Available (Line of Credit, Credit Cards, etc.)
                                                                                     Credit           Amount                   Credit
        Name of Institution                    Account Number                        Limit            Owed                     Available

                                                                         $                      $                             $

                                                                                     TOTAL (Enter also on Page 3, Item 24-C)  $

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IPA-BUS                                                                                                                             Page 2

                                         SECTION II - ASSETS (continued)

15. Real Property (including Investment Property, Unimproved Land, etc.)
        Description                      Address                                    Current Market Amount                    Equity In
                                                                                    Value          Owed                      Property
                                                                                 $$                $

                                                                                    Total (Enter also on Page 3, Item 24-D) $
16. Vehicles ( Excluding Leased Vehicles)
                                                                        Tag         Current Market Amount                    Equity In
        Description    Make              Model Year                     Number      Value          Owed                      Vehicle
                                                                                 $$ $

                                                                                    Total (Enter also on Page 3, Item 24-E) $
17. Accounts Receivable
                            Name                                                    Date Due       Status                    Amount Due
                                                                                                                            $

                                                                                    Total (Enter also on Page 3, Item 24-F) $

18. Loans From Business To Proprietor, Partners, Officers, Shareholders or Others
                       Name                         Relationship                    Payoff Date    Status                    Amount Due
                                                                                                                            $

                                                                                    Total (Enter also on Page 3, Item 24-G) $

19. Machinery and Equipment (Including Furniture, Fixtures, Business Machines, etc.)
                       Description                                                  Current Market Amount                    Equity In
                                                                                    Value          Owed                      Mach. & Equip.
                                                 $ $                                               $

                                                                                    Total (Enter also on Page 3, Item 24-H) $

20. Merchandise Inventory (Goods Held for Sales and/or Raw Materials Used in Manufacture Fabrication or Production)
                       Description                                                  Current Market Amount                    Equity In
                                                                                    Value          Owed                      Mach. & Equip.
                                                 $ $                                               $

                                                                                    Total (Enter also on Page 3, Item 24-I) $

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IPA-BUS Page 3

SECTION II - ASSETS (continued)

21. Securities (Stocks, Bonds, Mutual Funds, Government Securities, Money Market Funds, etc.)

Type Issuer Quantity or Current
Denomination Value
$

TOTAL (Enter also on Page 3, Item 24K) $

22. Other Assets
Current or Description Current or
Type Appraised Value Appraised Value
$

TOTAL (Enter also on Page 3, Item 24K) $

SECTION III - LIABILITIES

23. Liabilities
Total Amount Description Total Amount
Description Owed Owed
Notes Payable $ Past Due Federal Taxes $
Loans Payable Past Due State Taxes
Vehicle Leases Past Due Other Taxes
Equipment Leases Other Liabilities:
Bank Revolving Credit
Judgments Payable

TOTAL (Enter also on Page 3, Item 25) $

SECTION IV - NET WORTH CALCULATION
24. ASSETS
A. Cash On Hand $
B. Bank Accounts
C. Bank Credit Available
D. Real Property
E. Vehicles
F. Accounts Receivable
G. Loans From Business to Proprietor, Partners, Officers, Shareholders or Others
H. Machinery and Equipment
I. Merchandise Inventory
J. Securities
K. Other Assets
Total Assets $
25. LIABILITIES $

26. Net Worth (“Total Assets” Minus “Liabilities”) $

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IPA-BUS                                                                                                                                           Page 4

                                               SECTION V - INCOME & EXPENSE ANALYSIS
27. Business Income and Expenses For:  (Check One)   [   ]  Fiscal Year Ending                      OR   [   ]  Period                         to
                Accounting Method:   (Check One)    [   ] Cash   [   ]  Accrual   Other:

                Annual Income                             Amount                        Annual Expenses                                           Amount
Gross Receipts From Sales, Services, etc.             $            Materials Purchased                                                           $
Gross Rental Income                                                Net Wages & Salaries
Interest Income                                                    Rent or Mortgage Expenses
Dividends & Capital Gain Distribution                              Installment & Lease Payments
Royalty Income                                                     Supplies & Office Expenses
Commissions                                                        Utilities
Other Income (Specify)                                             Transportation Expenses
                                                                   Repairs & Maintanance
                                                                   Insurance
                                                                   Current Taxes
                                                                   Bad Debts
                                                                   Travel & Entertainment
                                                                   Advertising
                                                                   Other Expenses (Specify)

                                      Total Income    $                                      Total Expenses                                      $
28. Net Income (“Total Annual Income” Minus”Total Expenses”)                                                                                     $
                                                      SECTION VI - OTHER INFORMATION

29. Has this business disposed of any assets or property by sale, transfer, exchange, gift, or in any other manner during tha past 18 months?
[   ]  Yes     [   ]  No    If “Yes”, receiving party:

30. Is a foreclosure proceeding pending on any real estate, equipment or other property that this business owns or has an interest in?
[   ]  Yes     [   ]  No

31. Is another party holding any assets on behalf of this business?
[   ]  Yes     [   ]  No    If “Yes”, identify:

32. Is this business a party to any lawsuit now pending?
[   ]  Yes     [   ]  No

33. Is this business currently under bankruptcy court jurisdiction?
[   ]  Yes     [   ]  No    If “Yes”, Bankruptcy Case No.:

I/we have examined this Statement of Financial Condition for Businesses and hereby affirm that to the best of my/our knowledge and belief it is true,
correct and complete.
Taxpayer’s Signature                                                                    Date

Taxpayer’s Signature                                                                    Date

POA Signature                                                                           Date
                        (Must complete Power of Attorney - Use Department of Revenue Form RV-F0103801, enclosed)

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                       STATE OF TENNESSEE
                       DEPARTMENT OF REVENUE
                       ANDREW JACKSON STATE OFFICE BUILDING
                       NASHVILLE, TENNESSEE  37242

TO WHOM IT MAY CONCERN:

You have my authorization to release any financial data that pertains to me or my company to the Tennessee Department of
Revenue.

                       Signature

                       Date

                       SOCIAL SECURITY #

Sworn to and subscribed before me on the date of first above written.

                                                                     (Notary Public)

My commission expires:

RV-F0200501

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Tennessee Department of Revenue

INSTALLMENT PAYMENT AGREEMENT

SUPPORTING DOCUMENT CHECKLIST

Installment pay agreements submitted under the provisions of an inability to pay a tax in full will require an analysis of your
financial condition. To expedite this process, it is necessary that you provide the following information and documents along
with your initial application.

Copies of most current federal income tax returns for personal and/or business for the most current year.

Copies of most current bank statements for all checking and savings accounts, personal, and/or business for the
most current two months.
Statements from lending institutions that show current balances owed and monthly payment schedule. (i.e. bank
notes, car loans mortgages).
A list of all your business equipment, office furniture and other business assets, including the current fair market
value of each.

A list of all accounts receivable, (business), showing the payer, amount due, age and status of each account.

If personal liability applies, then you must provide proof of employment, income, commission, fees, pensions, etc.,
for yourself and spouse, if applicable. Even though your spouse may not be liable, this is necessary for equitable
distribution of cost of living expenses. A check stub or letter from your employer will do.

I have completed each item from the above document checklist. I have checked each item that is applicable. Any item that is
applicable. Any item that is not checked has been written through, “NA”.

Signature Date / /

Daytime Phone: ( )

Home Phone Number: ( )

For Office Use Only

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TENNESSEE DEPARTMENT OF REVENUE
POWER OF ATTORNEY

PART 1 Power of Attorney (Please type or print.)

1. Taxpayer Information (Taxpayer must sign and date this form on line 6.)
Taxpayer name and address Account number(s)

Daytime telephone number
( )
hereby appoints the following representative as attorney-in-fact:

2. Representative (Representative must sign and date this form on page 2, Part II.)
Name and address
Telephone No. ( )

Fax No. ( )

to represent the taxpayer before the Tennessee Department of Revenue for the following tax matters:

3. Tax Matters
Type of Tax (Sales and Use, Franchise, Excise, etc.) Year(s) or Period(s)

4. Acts Authorized. --The representative is authorized to receive and inspect confidential tax information and to perform any
and all acts that I can perform with respect to the tax matters described in line 3, for example, the authority to sign any
agreements, consents, or other documents. The authority does not include the power to receive refund checks.

5. Notices and Communication. --Notices and other written communications will be sent to the first representative listed in
line 2.

6. Signature of Taxpayer.- If signed by a corporate officer, partner, guardian, tax matters partner/person, executor, receiver,
administrator, or trustee on befalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the
taxpayer.

Signature Date Title (if applicable)

Print Name

RV-F0103801

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PART II Declaration of Representative

Under penalties of perjury, I declare that:
. I am authorized to represent the taxpayer(s) identified in Part 1 for the tax matter(s) specified there; and
. I am one of the following:
a. Attorney or Certified Public Accountant
b. Officer or full-time employee taxpayer organization
c. Other

If this declaration of representative is not signed and dated, the power of attorney will be returned.

Designation -- Insert
above letter (a-c)   Jurisdiction (state)             Signature                                               Date

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For additional information or assistance, contact the nearest
Revenue Collection Services Regional Office.

Memphis                        Chattanooga
3150 N. Appling Road           1301 Riverfront Parkway, Suite 203
Bartlett, TN  38133            Chattanooga, TN  37402
(901) 213-1451                 (423) 634-6288

Jackson                        Knoxville
Suite 301 Box 44               7175 Strawberry Plains Pike
State Office Building          Suite 300
225 Martin Luther King Jr. Dr. Knoxville, TN  37914
Jackson, TN  38301             (865) 594-6081
(901) 423-5745

Johnson City                   Nashville
204 High Point Dr.             Andrew Jackson State Office Bldg., 8th Floor
Johnson City, TN  37601        500 Deaderick St.
(423) 854-5364                 Nashville, TN  37242
                               (615) 360-0401

Deliver this application and all attachments to the following address:

PDF file checksum: 2100460766

(Plugin #1/10.13/13.0)