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Rev. 7/14

Form M-2848
Power of Attorney and
Declaration of Representative

Massachusetts
Department of
Revenue

See separate instructions. Please print or type.

Part 1. Power of Attorney
A Name of taxpayer(s) or principal reporting corporation

Social Security number(s)

Number and street, including apartment number or rural route

Federal Identification number

City/Town

State

Zip

B Hereby appoint(s) the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before any office of the Massachusetts Department of
Revenue for the following tax matter(s) (specify the type(s) of tax and year(s) or period(s) (date of death if estate tax)):
Name

Address

Type of tax (individual, corporate, etc.)

Telephone number

Year(s) or period(s) (date of death if estate tax)

C The attorney(s)-in-fact (or any of them) are authorized, subject to any limitations set forth below or to revocation, to receive confidential information and to
perform any and all acts that the princip