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Form RD-1061 (Rev. 10/2013)

Georgia Department of Revenue

Power of Attorney and Declaration of Representative
(Submit this form through GTC or to the Department Division which is handling your inquiry)

Section 1

Taxpayer Information (Taxpayer(s) must sign and date Section 5 of this form)

Taxpayer’s Name

Taxpayer’s Identification Number

Daytime Telephone Number

Spouse’s Name (if joint income tax return)

Spouse’s SSN (if applicable)

Daytime Telephone Number

Mailing Address

Spouse’s Mailing Address (if different from above)

Section 2

Representative Information (Certain Representative(s) may complete Section 7 of this form) Attach schedule if more than 2.

Name of person given power of attorney

Mailing Address

Telephone Number

City

Name of person given power of attorney

Mailing Address

Section 3

State

ZIP Code

Telephone Number

City

State

ZIP Code

Fax Number

Email Address

Fax Number

Email Address

Tax Matters

As attorney(s) -in-fact to represent the taxpayer(s