Pennsylvania Power of Attorney and Declaration of Representative

Power of Attorney and Declaration of Representative
Power of Attorney and Declaration of Representative (REV-677)
REV-677 LE (05-14)

POWER OF ATTORNEY AND
DECLARATION OF
REPRESENTATIVE
GENERAL INSTRUCTIONS:
This form provides limited authority for department representatives to speak about confidential tax matters with designated third parties. Such
authority is limited to the tax period, tax type and the specific issue/purpose identified herein.
While tax practitioners are encouraged to maintain appropriate declarations of authority to handle clients' tax matters within their
own records, tax practitioners should not submit unsolicited REV-677 forms to the department en masse or as a matter of routine.
Such forms will be disregarded.
A REV-677 form should only be submitted to an individual within the department upon an agent's request for such authorization.
If a department representative has requested a REV-677 form to authorize discussion of confidential tax matters with a third party, please return
the form to the department representative as requested.

PART I

Power of Attorney

NOTE: An organization, firm or partnership may not be designated as a taxpayer’s representative.

The following taxpayer
Identifying Number

START Taxpayer Name

➜
Address

State

City

ZIP

hereby appoints
Appointee Name(s)

Telephone Number

Address

City

Preparer Tax Identification Number (PTIN)
State

ZIP

as attorney-in-fact to represent the taxpayer before any office of the PA Department of Revenue for the following tax matter(s). Specify the
type(s) of tax, tax year(s) or period(s), tax return/report at issue and the specific purpose for which authorization to discuss confidential tax
matters with a third-party is sought.
Type(s) of tax

Tax Year(s) or Period(s)

Tax Return/Form

Purpose for Authorization

The attorney-in-fact is authorized, subject to revocation, to receive confidential information and perform any and all acts the principal can perform
with respect to the above-specified tax matters, excluding the power to receive refund checks and the power to sign the return, unless specifically
granted below.
Initial here
to grant the power to receive – but not to endorse or cash – refund checks for the above-referenced tax matters to
the appointee named above.
Only if this form is being submitted to the department in response to an audit, provide an address below to which copies may be sent of notices
and other written communications addressed to the taxpayer in proceedings involving the above-specified tax matters.
Appointee Name(s)

Telephone Number

Address

City

State

ZIP

This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the PA Department of Revenue for the
same matters and years or periods covered by this power of attorney, except the following:
Granter Name

Date

Address

City

MM/DD/YYYY

Refer to attached copies of
earlier powers and authorizations
State

ZIP

Signature of or for taxpayer
If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer, such party certifies he/she has the authority to execute this power
of attorney on behalf of the taxpayer.
Signature

PLEASE SIGN AFTER PRINTING.

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Title

Date

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MM/DD/YYYY

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If the power of attorney is granted to a person other than an attorney, certified public accountant or enrolled agent, the taxpayer's signature must
be witnessed or notarized below.

The person signing as or for the taxpayer (check and complete one):

is known to and signed in the presence of the two disinterested witnesses whose signatures appear here:

PLEASE SIGN AFTER PRINTING.
(Signature of Witness)

(Date)

MM/DD/YYYY

PLEASE SIGN AFTER PRINTING.
(Signature of Witness)

(Date)

MM/DD/YYYY

appeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.

PLEASE SIGN AFTER PRINTING.

Witness

(Signature of Notary)

NOTARIAL SEAL
(Date)

MM/DD/YYYY

PART II

Declaration of Representative

I declare that I am one of the following:
1

a member in good standing of the bar of the highest court of the jurisdiction indicated below;

2

duly qualified to practice as a certified public accountant in the jurisdiction indicated below;

3

a bona fide officer of the taxpayer organization;

4

a full-time employee of the taxpayer;

5

a member of the taxpayer’s immediate family (spouse, parent, child, brother or sister);

6

a fiduciary for the taxpayer; and/or

7

Other (specify)

;

and that I am authorized to represent the taxpayer identified in Part I for the tax matters specified therein.

DESIGNATION
(INSERT APPROPRIATE NUMBER
FROM ABOVE LIST)

JURISDICTION
(STATE, ETC.)

SIGNATURE

DATE
MM/DD/YYYY

PLEASE SIGN AFTER PRINTING.

PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.

PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.

PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.
PLEASE SIGN AFTER PRINTING.

PLEASE SIGN AFTER PRINTING.

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