7 Copies of notices and other written communications addressed to the taxpayer in proceedings involving the matters listed on the front of
this form should be sent to the following:
Name Name Name
Street address Street address Street address
City State ZIP City State ZIP City State ZIP
( )
( )
( )
Daytime phone number Daytime phone number Daytime phone number
Step 3: Taxpayer’s signature
If signing as a corporate officer, partner, fiduciary, or individual on behalf of the taxpayer, I certify that I have the authority to execute this
power of attorney on behalf of the taxpayer.
Taxpayer’s signature Title, if applicable Date
Spouse’s signature Title, if applicable Date
If corporation or partnership, signature of officer or partner Title, if applicable Date
Step 4: Complete the following if the power of attorney is granted to an attorney,
a certified public accountant, or an enrolled agent
I declare that I am not currently under suspension or disbarment and that I am
a member in good standing of the bar of the highest court of the jurisdiction indicated below; or
duly qualified to practice as a certified public accountant in the jurisdiction indicated below; or
enrolled as an agent pursuant to the requirements of United States Treasury Department Circular Number 230.
Designation (attorney, C.P.A., enrolled agent) Jurisdiction (state(s), etc.) Signature Date
Designation (attorney, C.P.A., enrolled agent) Jurisdiction (state(s), etc.) Signature Date
Designation (attorney, C.P.A., enrolled agent) Jurisdiction (state(s), etc.) Signature Date
Step 5: Complete the following if the power of attorney is granted to a person other
than an attorney, a certified public accountant, or an enrolled agent
If the power of attorney is granted to a person other than an attorney, a certified public accountant, or an enrolled agent, this document must
be witnessed or notarized below. Please check and complete one of the following.
Any person signing as or for the taxpayer
is known to and this document is signed in the presence of
the two disinterested witnesses whose signatures appear here.
Signature of witness Date
Signature of witness Date
appeared this day before a notary public and acknowledged
this power of attorney as his or her voluntary act and deed.
Signature of notary Date Notary seal
IL-2848 back (R-12/14)
*465202110*
This form is authorized as outlined under the Illinois Income Tax Act. Disclosure of
this information is required. Failure to provide information could result in a penalty.