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                                                                                                                                         Department Use Only
                                                          Form                                                                           (MM/DD/YY)
                                                                             Power of Attorney
                        2827

Taxpayer Missouri                                                                                                              Taxpayer Federal
Tax I.D. Number                                                                                                                Employer I.D. Number

Taxpayer Social                                                                                                                                          *14504010001*
Security Number                                                                                                                                                      14504010001
                                                                                              All appointed representatives must sign on reverse side of this form.
Taxpayer’s Name or Business Name                                                                                               

Spouse’s Name or if a DBA, state the business name                                                                                                       Spouse’s Social Security Number
                                                                                                                                                          |        |        |        |        |        |        |        |        |
Street Address                                                                                                                                                    Missouri Charter Number 
                                                                                                                                                         |         |        |        |        |        |        |        |        |        |  
City                                                                                                          State           Zip Code                   Telephone Number
                                                                                                                                                         (__ __ __) __ __ __ - __ __ __ __
E-mail Address                                                                                                                 

                                                                    Name of Appointed Representative           Address 

                                                                    Telephone Number                           E-mail Address 
                                                                    (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                                    Name of Appointed Representative           Address

                                                                    Telephone Number                           E-mail Address 
                                                                    (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                                    Name of Appointed Representative           Address

                                        Representative(s)           Telephone Number                           E-mail Address 
                                                                    (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                                    Name of Appointed Representative           Address

                                                                    Telephone Number                           E-mail Address
                                                                    (___ ___ ___) ___ ___ ___-___ ___ ___ ___

                                                                    r Cigarette or Other Tobacco Products    r Income Tax              r Pass-through Entity Tax   r     Medical and Recreational 
                                                                    r   Motor Fuel                           r Sales or Use            r   Withholding                   Marijuana Tax* 
                                                                                                                                                                         *Not Local Marijuana Sales Tax 
                                        Tax Type(s)                 r Other _________________________________________________________________________________________

                                                                    Only select one of the following:
                                                                    r  All Tax Periods                    r  Tax Year or Period(s) Only ___________________________________________
                                                                    r Range of Tax                        r Date of Death (if estate tax) ___ ___ / ___ ___ / ___ ___ ___ ___ 
            Year(s) and                                   Period(s)   Tax Period Beginning ___ ___ / ___ ___ / ___ ___ ___ ___  to Tax Period Ending ___ ___ / ___ ___ / ___ ___ ___ ___

                                                                    r All other powers of attorney on file with the Department shall remain in effect, or
                                                                    r By execution of this power of attorney, all earlier powers of attorney on file with the Department are hereby revoked, except the 
                                                                      following: (specify to whom the power of attorney was granted, date and address, or refer to attached copies of earlier powers of attorney  
                                                                      and authorizations.)  Attach additional forms if needed.

                        Removal of Power

Under penalties of perjury, I (we) hereby certify that I (we) am (are) the taxpayer(s) named herein or that I have the authority to execute this 
power of attorney on behalf of the taxpayer(s). 
Name Title (if applicable)

Signature Date (MM/DD/YYYY) Taxpayer Telephone Number
__ __ / __ __ / __ __ __ __ (___ ___ ___) ___ ___ ___-___ ___ ___ ___
Signature
Name Title (if applicable)

Signature Date (MM/DD/YYYY) Taxpayer Telephone Number
__ __ / __ __ / __ __ __ __ (___ ___ ___) ___ ___ ___-___ ___ ___ ___

NOTE: If Pass-through Entity Tax is selected see page 3 for member(s) signature(s).
Current mailing and email address, as well as telephone number, must all be entered for the Affected Business Entity Representative .

Please consult Missouri Regulation 12 CSR 10-41.030 for any questions about who may serve as an attorney(s)-in-fact and what additional 
documentation may be required.
I declare that I am aware of Regulation 12 CSR 10-41.030 and that I am authorized to represent the taxpayers identified above for the tax 
matters there specified and that I am one of the following:
1.  a member in good standing of the bar; 5.  a fiduciary for the taxpayer;
2.  a certified public accountant duly qualified to practice; 6.  an enrolled agent;
3.  an officer of the taxpayer organization; 7.  tax preparer, or
4.  a full-time employee of the taxpayer; 8.  other authorized representative or agent
Note: All appointed representatives must sign below. 
If the representative is to serve as an Affected Business Entity Representative, fill in the Title of that person as “Affected Business Entity  
Representative”.

Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
  ___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above)  Title (if applicable)
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8 
Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
  ___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above)  Title (if applicable) 
Declaration of Representative(s)
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8 
Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
  ___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above)  Title (if applicable) 
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8 
Printed Name of Representative Signature of Representative Date (MM/DD/YYYY)
  ___ ___ / ___ ___ / ___ ___ ___ ___
Designation (Please select number from list above)  Title (if applicable) 
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8 

*14504020001*
14504020001

                                                          Under penalties of perjury, I (we) hereby certify that I (we) am (are) members of, or an officer or manager of, the taxpayer named on this Form 
                                                          2827, and that I (we together) am (are) authorized to designate an affected business entity representative for the taxpayer.
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)
                             Pass-through Entity Member(s)
                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                                                          Name                                     Title (if applicable)

                                                          Signature                                Date (MM/DD/YYYY)                Taxpayer Telephone Number
                                                                                                   __ __ / __ __ / __ __ __ __   (___ ___ ___) ___ ___ ___-___ ___ ___ ___

                                                                                                                                                                                      Form 2827 (Revised 04-2024)
Mail to:
(Business Tax)                                                      (Personal Tax)                    (Motor Fuel Tax)              (Cigarette or Other Tobacco Products Tax)                                     
Taxation Division                                                   Taxation Division                 Taxation Division             Taxation Division
P.O. Box 357                                                        P.O. Box 2200                     P.O. Box 300                  P.O. Box 811 
Jefferson City, MO  65105-0357                                      Jefferson City, MO  65105-2200    Jefferson City, MO 65105-0300 Jefferson City, MO 65105-0811
Phone:  (573) 751-5860                                              Phone:  (573) 751-3505            Phone:  (573) 751-2611        Phone:  (573) 751-7163
Fax:  (573) 522-1722                                                Fax:  (573) 522-1762              Fax: (573) 522-1720           Fax:  (573) 522-1720
E-mail:  businesstaxregister@dor.mo.gov                             E-mail:  income@dor.mo.gov        E-mail:  excise@dor.mo.gov    E-mail: DOR.tobacco@dor.mo.gov 

(Pass Through Entity Tax)
Taxation Division
P.O. Box 3080
Jefferson City, MO 65105-3080
Phone:  (573) 751-5860                                              If this is being submitted in response to an audit, please fax to (573) 522-6922.
Fax:  (573) 522-1721
TTY: (800) 735-2966
E-mail: corporate@dor.mo.gov                                                Visit dor.mo.gov/ for additional information.

                                                                        *14504030001*
                                                                                           14504030001