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REV184

Power of Attorney
Taxpayer
Information

Read the instructions on the back before completing this form.
Taxpayer’s name (person or business)

Social Security or Minnesota tax ID number (or federal ID number)

Spouse’s name (if a joint income tax return)

Spouse’s Social Security number (if a joint income tax return)

Street address

City

State

ZIP code

Power of Attorney

Check only one (see instructions):
Add—appoints a new power of attorney authorizing the appointee(s)

Change—changes an existing power
of attorney for the appointee(s)

Remove—ends the power of attorney for
the appointee(s)

Primary appointee: Name of person given power of attorney
Street address

City

State

ZIP code

Phone number

Fax number

Email address

If removing an appointee, skip the next two sections, then sign and date the form.
I appoint the above person, and anyone included on the attachment, as attorney-in-fact to represent me before the Minnesota Department of Revenue. It is
my responsibility