Form 2827 Power Of Attorney
User Manual: 2827
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Form
2827 Missouri Department of Revenue
Power of Attorney
Department Use Only
(MM/DD/YY)
Taxpayer Missouri
Tax I.D. Number
Taxpayer Federal
Employer I.D. 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
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
Telephone Number E-mail Address
Name of Appointed Representative Address
Telephone Number E-mail Address
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Representative(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 _____________________________________________________________________________________________________________________
Tax Type(s)
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 ___ ___ / ___ ___ / ___ ___ ___ ___
Year(s) and
Period(s)
*14504010001*
14504010001
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
Taxpayer Social
Security Number
| | | | | | | | | |
Please print on white paper only
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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
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Signature
(___ ___ ___)___ ___ ___-___ ___ ___ ___
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
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
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.
Declaration of Representative(s)
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) 751-2195 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: excise@dor.mo.gov
Visit http://dor.mo.gov/ for additional information.
Form 2827 (Revised 11-2016)
*14504020001*
14504020001
No digital signatures allowed
