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. No digital signatures allowed.
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 04-2018)
*14504020001*
14504020001
