Kentucky Kentucky Tax Declaration of Representative / Power of Attorney

Kentucky Tax Declaration of Representative / Power of Attorney
Form 20A100
FORM

20A100

DECLARATION OF REPRESENTATIVE

Commonwealth of Kentucky
Department of Revenue

1	 TAXPAYER INFORMATION: Please type or print.	

Enter only those that apply.

Taxpayer Name	

Federal Taxpayer Identification Number

Mailing Address - Number and Street	
City	

State	

Apartment/Suite No.	
Zip Code	

E-mail Address

Daytime Phone

2	 REPRESENTATIVE(S) INFORMATION	

Enter applicable identification number.

Name	

State and State Bar Number

Mailing Address - Number and Street	
City	

State	

Apartment/Suite No.	
Zip Code	

State and CPA License Number

Daytime Phone		

IRS Enrolled Agent Number

Name	

State and State Bar Number

Mailing Address - Number and Street	
City	

State	

Apartment/Suite No.	
Zip Code	

State and CPA License Number

Daytime Phone		

IRS Enrolled Agent Number

Name	

State and State Bar Number

Mailing Address - Number and Street	
City	

State	

Apartment/Suite No.	
Zip Code	

State and CPA License Number

Daytime Phone		

IRS Enrolled Agent Number

3	 TAX MATTERS: The taxpayer appoints the above representative(s) for purposes of duly authorized representation
in any proceeding with the Kentucky Department of Revenue with respect to the tax matters indicated below. If no tax
form number or tax year is provided, this form will be valid for all tax types, tax years, and authorized acts selected
until revoked.
TAX TYPE
	

¨

Corporation Income/Limited Liability
Entity Tax

¨

Individual Income Tax

¨

Sales and Use Tax

¨

Property Tax

¨

Other (Please Specify)

ACCOUNT NUMBER

TAX FORM NUMBER
(740, 720, 51A205, etc.)

TAX YEAR(S) OR PERIOD(S)

4	 AUTHORIZED ACTS: The representative(s) listed above is authorized to receive, inspect, and discuss the
taxpayer’s confidential tax information. The taxpayer also authorizes the following acts:

¨

Representative has the authority to sign a statute of limitations waiver on Taxpayer’s behalf.

¨

Representative has the authority to execute a protest on Taxpayer’s behalf.

¨

Representative has the authority to represent Taxpayer in any administrative tax proceeding, including conferences.

¨

Representative has the authority to receive notices and communications (unless system generated) from the Department of
Revenue.

¨

Representative has the authority to represent Taxpayer in any collection matter, including an Offer-in-Settlement.

¨

Representative may obtain Taxpayer’s CBI number and execute changes to Taxpayer’s account.

¨

Other acts. (Please specify)_________________________________________________________________________________________

20A100 (10-19)	

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DECLARATION OF REPRESENTATIVE

FORM 20A100

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5	 CONSOLIDATED OR UNITARY COMBINED RETURN FILERS: If the taxpayer files a consolidated or unitary combined
tax return per KRS 141.200(11) and/or KRS 141.201(3)(a), the authorized acts will be extended to the subsidiaries
included in the return. If any subsidiaries are to be excluded from the authorized acts, list below.
NAME

FEDERAL IDENTIFICATION
NUMBER

TAX YEARS

6	 RETENTION/REVOCATION OF PRIOR POWER(S) OF ATTORNEY OR REPRESENTATIVE AUTHORIZATION(S)

The filing of this authorization form automatically revokes any prior power(s) of attorney or representative authorization(s) on file
with the Department of Revenue for the same matter(s) and year(s) or period(s) covered by this document. If you do not want to
revoke any prior power(s) of attorney or representative authorization(s), you must attach a copy of any power(s) of attorney or
representative authorization(s) you wish to remain in effect for the same matter(s) and year(s) or period(s) covered.

7	

SIGNATURE OF TAXPAYER. If a tax matter concerns a year in which a joint return was filed, each spouse must file a separate
representative authorization even if they are appointing the same representative(s). If signed by a corporate officer, partner,
guardian, tax matters partner, executor, receiver, administrator, or trustee on behalf of the taxpayer, I certify that I have the legal
authority to execute this form on behalf of the taxpayer.
NOT VALID UNLESS COMPLETED, SIGNED, AND DATED BY THE TAXPAYER.

Signature	

Date Signed

Print Name	

Title (if applicable)

8	 SIGNATURE OF REPRESENTATIVE(S)

Under penalties of perjury, by my signature below I declare that:
•	 I am not currently suspended or disbarred from practice, or ineligible for practice;
•	 I am subject to regulations contained in Circular 230 (31 CFR, Subtitle A, Part 10) as amended, governing practice before the
Internal Revenue Service;
•	 I am authorized to represent the taxpayer for the matter(s) specified; and
NOT VALID UNLESS COMPLETED, SIGNED, AND DATED BY THE REPRESENTATIVE(S).
Signature		

Date Signed

Printed Name		

PTIN (if applicable)

Signature		

Date Signed

Printed Name		

PTIN (if applicable)

Signature		

Date Signed

Printed Name		

PTIN (if applicable)

Instructions for Form 20A100

FORM 20A100

4	 Authorized Acts

Purpose of Form 20A100
Use the Declaration of Representative (Form 20A100)
to authorize the individual(s) to represent you before
the Kentucky Department of Revenue. You may grant
the individual(s) authorization to act on your behalf
with regard to any tax administered by the Kentucky
Department of Revenue. Form 20A100 is provided for
the taxpayer’s convenience. One form may be submitted
to designate all tax types the Department is authorized
to communicate with the authorized representative(s).
You may revoke this form at any time.
1	 Taxpayer Information—enter the following:

Daytime Phone—Enter the taxpayer’s telephone
number.
Federal Taxpayer Identification Number—Enter
the federal identification number. For individuals,
this will be your social security number. For
business entities, this will be your federal employer
identification number (FEIN).
the

taxpayer’s

This form allows the authorized representative(s)
to communicate and receive confidential tax
information. You may also select other acts the
authorized representative(s) may perform on your
behalf. If an act is not listed, select “Other” and
specify.
Note: This form does not allow the authorized
representative to sign tax returns or settlement
agreements on your behalf.
5	 Consolidated or Unitary Combined Return Filers

Name and Address—Print or type the name of the
taxpayer submitting this form. For the address,
include the suite, room, or other unit number after
the street address. If the U.S. Postal Service does not
deliver to the street address and the taxpayer has
a P.O. box, include the box number instead of the
street address.

E-mail Address—Enter
address.

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If a consolidated or unitary combined tax return has
been filed, list any subsidiary(ies) to be excluded
from this authorization. The Department will not
discuss or provide confidential tax information to
the authorized representative(s) for any subsidiary
listed. If no subsidiaries are listed, this form will
extend to all corporations in a consolidated or
unitary combined tax return.
6	 Retention/Revocation
Filing this form will automatically revoke any prior
power of attorney or authorization letter submitted
to the Department for the tax matters included on
this form. If you do not want to revoke a prior power
of attorney or authorization letter, a copy MUST be
attached to this form to remain in effect.

e-mail

2	 Representative Information
Enter up to three individuals authorized to represent
you and act on your behalf before the Department
about the tax matters and authorized acts specified on
this form. Provide the name, address, and telephone
number of the authorized representative(s). If the
authorized representative is an attorney, certified
public accountant (CPA), or enrolled agent, provide
the appropriate identification number.
3	 Tax Matters
Select the tax types the authorized representative(s)
may act on your behalf with the Department. Provide
the account number for all tax types selected. If
authorization is being granted for specific forms and
tax periods, list the tax forms and tax periods. If tax
forms and tax periods are left blank, this form will
be valid for all tax types, tax periods, and authorized
acts selected until revoked.

7	 Signature of Taxpayer
This form must be signed and dated by the taxpayer
to be valid. If the taxpayer is a business entity, it
must be signed by an individual with the authority
to delegate a representative on behalf of the
taxpayer. If not signed and dated, the Department
will not communicate with or provide confidential
tax information to the authorized representative(s)
included on this form.
8	 Signature of the Authorized Representative(s)
This form must be signed and dated by the
authorized representative(s) to be valid. If not signed
and dated, the Department will not communicate
with or provide confidential tax information to the
authorized representative(s) included on this form.
Mail this form to the following address:

Kentucky Department of Revenue
P. O. Box 181, Station 56
Frankfort, Kentucky 40602-0181