Form 2827 Power Of Attorney

User Manual: 2827

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2827

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Department Use Only
(MM/DD/YY)

Missouri Department of Revenue
Power of Attorney

Taxpayer Missouri

Taxpayer Federal

Tax I.D. Number

Employer I.D. Number

*14504010001*
14504010001

Taxpayer Social
Security Number

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
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Street Address		

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City

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Missouri Charter Number
State

Zip Code

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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

Telephone Number

E-mail Address

Name of Appointed Representative

Address

Telephone Number

E-mail Address

Representative(s)

(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___

Removal of Power

Year(s) and
Period(s)

Tax Type(s)

(___ ___ ___)___ ___ ___-___ ___ ___ ___

r Cigarette or Other Tobacco Products r Corporation Income and Corporation Franchise
r Personal Income
r Motor Fuel		
r Sales or Use				
r Withholding
r Other _____________________________________________________________________________________________________________________
r All Tax Periods		

r Tax Year or Period(s) Only ___________________________________________

r Range of Tax 		

r Date of Death (if estate tax) ___ ___ / ___ ___ / ___ ___ ___ ___

Tax Period Beginning ___ ___ / ___ ___ / ___ ___ ___ ___ to Tax Period Ending ___ ___ / ___ ___ / ___ ___ ___ ___

r
r

All other powers of attorney on file with the Department shall remain in effect, or
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.

Signature

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

(

)

-

__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name

Title (if applicable)

Signature

Date (MM/DD/YYYY)

Taxpayer Telephone Number

(

)

-

__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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:

Declaration of Representative(s)

1.
2.
3.
4.

a member in good standing of the bar;
a certified public accountant duly qualified to practice;
an officer of the taxpayer organization;
a full-time employee of the taxpayer;

5.
6.
7.
8.

Note: All appointed representatives must sign below.
Printed Name of Representative

a fiduciary for the taxpayer;
an enrolled agent;
tax preparer, or
other authorized representative or agent

No digital signatures allowed

Signature of Representative

		

___ ___ / ___ ___ / ___ ___ ___ ___

Designation (Please select number from list above)		

r

1

r

2

r

3

r

4

r

5

r

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Printed Name of Representative

7

Title (if applicable)

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Signature of Representative

		
Designation (Please select number from list above)		

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1

r

2

r

3

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4

r

5

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6

r

Printed Name of Representative

7

___ ___ / ___ ___ / ___ ___ ___ ___

r

8

Signature of Representative

r

2

r

3

r

4

r

5

r

6

r

Printed Name of Representative

7

Title (if applicable)

r

8

Signature of Representative

		

1

r

2

r

3

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Title (if applicable)

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Form 2827 (Revised 11-2016)

Mail to:
(Business Tax)
Taxation Division
P.O. Box 357
Jefferson City, MO 65105-0357
Phone: (573) 751-5860
Fax: (573) 522-1722
E-mail: businesstaxregister@dor.mo.gov

Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___

Designation (Please select number from list above)		

r

Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___

Designation (Please select number from list above)		
1

Date (MM/DD/YYYY)

Title (if applicable)

		

r

Date (MM/DD/YYYY)

(Personal Tax)
Taxation Division
P.O. Box 2200
Jefferson City, MO 65105-2200
Phone: (573) 751-3505
Fax: (573) 751-2195
E-mail: income@dor.mo.gov

(Motor Fuel Tax)
Taxation Division
P.O. Box 300
Jefferson City, MO 65105-0300
Phone: (573) 751-2611
Fax: (573) 522-1720
E-mail: excise@dor.mo.gov

Visit http://dor.mo.gov/ for additional information.

*14504020001*
14504020001

(Cigarette or Other Tobacco Products Tax)		
Taxation Division
P.O. Box 811
Jefferson City, MO 65105-0811
Phone: (573) 751-7163
Fax: (573) 522-1720
E-mail: excise@dor.mo.gov
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Title                           : Form 2827 - Power of Attorney
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Author                          : Missouri Department of Revenue
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