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Power Of Attorney LGL-001 - Connecticut
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Department of Revenue Services State of Connecticut 25 Sigourney Street Hartford CT 06106-5032 (Rev. 06/06) Taxpayer's Name LGL-001 Power of Attorney Social Security Number Social Security Number Connecticut Tax Registration Number State ZIP Code Federal Employer ID Number Part I: Taxpayer(s) Giving a Power of Attorney to Another Person Spouse's Name (Personal income tax or individual use tax only) Mailing Address City Taxpayer is: (Check box) Corporation Individual Partnership Sole Proprietorship Business Trust Trust (other than a business trust) Other (specify) Estate Limited Liability Company Part II: Declaration of the Person Giving Power of Attorney to the Person(s) Named in Part III See instructions for who may execute this power of attorney and required documentation. This power of attorney revokes all previous powers of attorney on file with the Department of Revenue Services (DRS) for the same tax matters and years or periods covered by this power of attorney. Declaration: I am the taxpayer identified in Part I, or if I am not the taxpayer identified in Part I, I have been authorized by the taxpayer to execute this power of attorney on behalf of the taxpayer and I am permitted by the instructions on this Form LGL-001 to execute this power of attorney. I declare under penalty of law that I have examined this document (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both. Print Name: ____________________________________________________________ Signature: _____________________________________________________________ Title: ___________________________________________ Date: __________________________________________ Part III: Power of Attorney Given To The taxpayer(s) named above appoints the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before DRS for the following tax matters. Specify all tax types and periods affected. Use the date of death for succession and estate taxes. Name Address Telephone Number Type of Tax (Corporation Business Tax, Admissions Tax, etc.) Year(s) or Period(s) Part IV: Powers Given Any of the attorney(s)-in-fact are authorized, subject to revocation, to receive confidential information and to perform on behalf of the taxpayer(s) the following acts for the tax matters described above. The authority does not include the power to sign certain returns unless specifically stated below. Check the boxes for the powers given: To receive, but not to endorse and collect, checks (made payable to the taxpayer mentioned above) in payment of any refund of Connecticut taxes, penalties, or interest. To execute waivers (including offers of waivers) of restrictions on assessment or collection of deficiencies in tax and waivers of notice of disallowance of a claim for credit or refund. To execute or terminate consents extending the statutory period for assessment or collection of tax. To execute closing agreements under Conn. Gen. Stat. §12-2e. To delegate authority or to substitute another representative. To represent the taxpayer(s) named above before DRS. To request tax returns or tax return information. (Must submit with LGL-002.) To sign returns (See instructions.) Authorized Signature Spouse's Signature Part V: Declaration of Person Receiving Power of Attorney I declare under penalty of law that I have examined this document (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge. Signature Title Date American LegalNet, Inc. www.FormsWorkflow.com Instructions Use LGL-001, Power of Attorney, to authorize one or more individuals to represent you before DRS. Your authorization allows your representative(s) to receive and inspect confidential tax information and to act on your behalf in matters before DRS. DRS will continue to send all mailings, such as billing notices, directly to the taxpayer and not to the person designated as power of attorney. Part I: Taxpayer(s) Giving a Power of Attorney to Another Person Provide the taxpayer's name and address and either your Social Security Number (SSN) or Connecticut Tax Registration Number and Federal Employer Identification Number. If you are a sole proprietor, enter your name and SSN. Do not enter your trade name. Do not use your representative's address as your own. Your spouse's name is not required except for joint personal income tax or individual use tax returns. If you are filing a joint personal income tax return and you and your spouse have the same representative(s), include your spouse's name and SSN in the space provided. Otherwise, each spouse must file a separate LGL-001. Check the box that describes the taxpayer. Part II: Declaration of the Person Giving Power of Attorney to the Person(s) Named in Part III Any person giving a power of attorney to another person(s) must sign this declaration and attach the requested documentation to support the status that entitles you to give this power of attorney. Who may execute this power of attorney? · Any individual if the request is for an income tax return filed by that individual (or filed by that individual and his or her spouse if the request is for a joint income tax return); Conn. Agencies Regs. §12-725-1(b) allows an agent, or a fiduciary charged with the care of the person or property of the taxpayer, to make and sign a return only when illness, absence, minority, or other good cause prevents the person required or permitted to make or file a Connecticut income tax return from doing so. You must state a reason why the taxpayer cannot sign the return. · A limited liability company (LLC) member if the taxpayer is an LLC and has no manager; or a manager if the taxpayer is an LLC and has managers (Attach a copy of the articles of organization or operating agreement. If the member or manager is a corporation or partnership, refer to the rules listed below for these entities.); · The sole proprietor if the taxpay
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