Fillable POWER OF ATTORNEY CALIFORNIA DEPARTMENT OF TAX AND (California)

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POWER OF ATTORNEY CALIFORNIA DEPARTMENT OF TAX AND (California)

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CDTFA-392 (FRONT) REV. 12 (3-21) STATE OF CALIFORNIA
POWER OF ATTORNEY CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION
EMPLOYMENT DEVELOPMENT DEPARTMENT
Check below to indicate the appropriate agency. Please note that a separate form must be completed and provided to each agency checked.
CALIFORNIA DEPARTMENT OF
TAX AND FEE ADMINISTRATION
PO BOX 942879
SACRAMENTO, CA 94279-0001
1-800-400-7115 (CRS:711)
EMPLOYMENT DEVELOPMENT DEPARTMENT
PO BOX 826880 MIC:28
SACRAMENTO, CA 94280-0001
1-916-654-7263 • FAX 1-916-654-9211
TAXPAYER’S NAME BUSINESS OR CORPORATION NAME TELEPHONE NUMBER FAX NUMBER
SOCIAL SECURITY NUMBER FEDERAL EMPLOYER IDENTIFICATION NUMBER CALIFORNIA SECRETARY OF STATE NUMBER(S)
CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION ACCOUNT/PERMIT(S) EDD EMPLOYER ACCOUNT NUMBER
MAILING ADDRESS (number and street, city, state, ZIP Code)
EMAIL ADDRESS
Individual Partnership Corporation Limited Liability Company
Other
As owner, officer, receiver, administrator, or trustee for the taxpayer, or as a party to the tax or fee matter before the:
California Department of Tax and Fee Administration Employment Development Department
I hereby appoint: [
enter below the name(s) of the individual appointee(s), their address(es) (including ZIP Code), their
telephone number(s) and fax number(s
)—do not enter names of accounting or law firms, partnerships, corporations, among
others, as the appointee name]
APPOINTEE NAME APPOINTEE NAME
APPOINTEE BUSINESS NAME (if applicable) APPOINTEE BUSINESS NAME (if applicable)
APPOINTEE ADDRESS (number and street) APPOINTEE ADDRESS (number and street)
(city) (state) (ZIP Code) (city) (state) (ZIP Code)
EMAIL ADDRESS EMAIL ADDRESS
TELEPHONE NUMBER FAX NUMBER TELEPHONE NUMBER FAX NUMBER
As attorney(s)-in-fact to represent the taxpayer(s) for the following tax or fee matter(s): [specify type(s) of tax]
Tax and fee programs administered by CDTFA
Payroll tax law
Benefit reporting
Other:
SPECIFY THE TAX OR FEE YEAR(S) OR PERIOD(S)
(The back of this form must be completed)
CDTFA-392 (BACK) REV. 12 (3-21)
The attorney(s)-in-fact (or any of them) are authorized, subject to revocation, to receive confidential tax information,
and to perform on behalf of the taxpayer(s) the following act(s) for the tax or fee matter(s) described above:
[check the box(es) for the power(s) granted]
General authorization (including all acts described below).
Specific authorization (selected acts described below).
To confer and resolve any assessment, claim, or collection of a deficiency or other tax or fee matter pending before the
identified agency and attend any meetings or hearings thereto for the specified law identified above.
To receive, but not to endorse and collect, checks in payment of any refund of taxes, penalties, or interest.
To execute petitions, claims for refund, and/or amendments thereto.
To execute consents extending the statutory period for assessment or determination of taxes.
To represent the taxpayer for changes to their mailing address for any and all payroll tax law, benefit reporting, or both
payroll tax law and benefit reporting.
To execute settlement agreements under section 1236 of the California Unemployment Insurance Code.
To delegate authority or to substitute another representative.
Other (specify):
This power of attorney revokes all earlier power(s) of attorney on file with the California Department of Tax and Fee
Administration or the Employment Development Department as identified above for the same matters and years or
periods covered by this form, except for the following: [specify to whom granted, date and address, or refer to attached
copies of earlier power(s)]
NAME DATE POWER OF ATTORNEY GRANTED
ADDRESS (number and street, city, state, ZIP Code)
Unless limited, this power of attorney will remain in effect until the final resolution of all tax or fee matters specified
herein.
(specify expiration date if limited term)
TIME LIMIT/EXPIRATION DATE (for California Department of Tax and Fee Administration purposes)
Signature of taxpayer(s)—If a tax or fee matter concerns a joint return, both spouses must sign if joint representation is
requested. If you are a corporate officer, partner, guardian, tax or fee matters partner/person, executor, receiver, registered
domestic partner, administrator, or trustee on behalf of the taxpayer, by signing this power of attorney, you are certifying that you
have the authority to execute this form on behalf of the taxpayer.
► IF THIS POWER OF ATTORNEY IS NOT SIGNED AND DATED BY AN AUTHORIZED INDIVIDUAL, IT WILL BE RETURNED AS INVALID.
SIGNATURE TITLE (if applicable) DATE
PRINT NAME TELEPHONE NUMBER
SIGNATURE TITLE (if applicable) DATE
PRINT NAME TELEPHONE NUMBER
CLEAR
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POWER OF ATTORNEY CALIFORNIA DEPARTMENT OF TAX AND (California)

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Completed 29 November 2021

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