Missouri Power of Attorney

Power of Attorney
2827 - Power of Attorney
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Please print on white paper only

Department Use Only
(MM/DD/YY)

Form

2827

Power of Attorney

Taxpayer Missouri

Taxpayer Federal

Tax I.D. Number

Employer I.D. Number

*14504010001*
14504010001

Taxpayer Social
Security 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
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Street Address		

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City	

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Missouri Charter Number
State 	

Zip Code	

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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)

(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___

Removal of Power

Year(s) and
Period(s)

Tax Type(s)

(___ ___ ___)___ ___ ___-___ ___ ___ ___

r Cigarette or Other Tobacco Products	 r  Income Tax		 r  Pass-through Entity Tax	
r  Motor Fuel		
r  Sales or Use		 r  Withholding
r  Other _____________________________________________________________________________________________________________________
Only select one of the following:

r All Tax Periods		
r	Range of Tax 		
	

r Tax Year or Period(s) Only ___________________________________________
r Date of Death (if estate tax) ___ ___ / ___ ___ / ___ ___ ___ ___

Tax Period Beginning ___ ___ / ___ ___ / ___ ___ ___ ___ to Tax Period Ending ___ ___ / ___ ___ / ___ ___ ___ ___

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.

Signature

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

(

)

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__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

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__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
NOTE: If Pass-through Entity Tax is selected see page 3 for member(s) signature(s).
Current mailing and email address, as well as telephone number, must all be entered for the Affected Business Entity Representative .

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:

Declaration of Representative(s)

1.	
2.	
3.	
4.	

a member in good standing of the bar;	
a certified public accountant duly qualified to practice;	
an officer of the taxpayer organization;	
a full-time employee of the taxpayer;	

5.	
6.	
7.	
8.	

a fiduciary for the taxpayer;
an enrolled agent;
tax preparer, or
other authorized representative or agent

Note: All appointed representatives must sign below.
If the representative is to serve as an Affected Business Entity Representative, fill in the Title of that person as “Affected Business Entity
Representative”.
Printed Name of Representative	

Signature of Representative	

		
Designation (Please select number from list above)		

Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___

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	

		
Designation (Please select number from list above)		

Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___

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	

		
Designation (Please select number from list above)		

Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___

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	

		
Designation (Please select number from list above)		

Date (MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___

Title (if applicable)	

r	 1	 r	 2	 r	 3	 r	 4	 r	 5	 r	 6	 r	 7	 r	 8

*14504020001*
14504020001

Under penalties of perjury, I (we) hereby certify that I (we) am (are) members of, or an officer or manager of, the taxpayer named on this Form
2827, and that I (we together) am (are) authorized to designate an affected business entity representative for the taxpayer.
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

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__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

-

__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

-

Pass-through Entity Member(s)

__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

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__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

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__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

-

__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

-

__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

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__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name	

Title (if applicable)

Signature	

Date (MM/DD/YYYY)	

Taxpayer Telephone Number

(

)

-

__ __ / __ __ / __ __ __ __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Form 2827 (Revised 11-2022)

Mail to:
(Business Tax)	
Taxation Division	
P.O. Box 357	
Jefferson City, MO 65105-0357	
Phone: (573) 751-5860	
Fax: (573) 522-1722	
E-mail: [email protected]	
(Pass Through Entity Tax)
Taxation Division
P.O. Box 3080
Jefferson City, MO 65105-3080
Phone: (573) 751-5860
Fax: (573) 522-1721
TTY: (800) 735-2966
E-mail: [email protected]

(Personal Tax)	
Taxation Division	
P.O. Box 2200	
Jefferson City, MO 65105-2200	
Phone: (573) 751-3505	
Fax: (573) 522-1762	
E-mail: [email protected]	

(Motor Fuel Tax)	
Taxation Division	
P.O. Box 300	
Jefferson City, MO 65105-0300	
Phone: (573) 751-2611	
Fax: (573) 522-1720	
E-mail: [email protected]	

(Cigarette or Other Tobacco Products Tax)		
Taxation Division
P.O. Box 811	
Jefferson City, MO 65105-0811
Phone: (573) 751-7163
Fax: (573) 522-1720
E-mail: [email protected]

If this is being submitted in response to an audit, please fax to (573) 522-6922.

Visit dor.mo.gov/ for additional information.

*14504030001*
14504030001