Massachusetts Department of Revenue. International Fuel Tax Agreement (IFTA) Massachusetts License Application
Massachusetts Department of Revenue. XXXXXXXX'S ADDRESS FEDERAL IDENTIFICATION NUMBER EMPLOYER'S CITY EMPLOYER'S STATE AND ZIP CODE XXXXXXX XXXXXXXX 000 XXXXXXXXXX XXXXXX XXXXX XXXXXXXXX, XX 00000 (000) 000-0000 Type of tax (individual, corporate, etc.) Year(s) or period(s) (date of death if estate tax) INCOME TAX WITHHOLDING, TA-1 ALL 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)): 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 principal(s) can perform with respect to the above specified tax matters, such as the authority to sign any agreements, consents or other documents.The authority does not include the power to substitute another representative (unless specifically added below) or the power to receive refund checks. List any specific additions or deletions to the acts otherwise authorized in this power of attorney: D Originals of notices and other written communications go to the taxpayer(s). Send copies of all notices and all other written communications addressed to the taxpayer(s) in proceedings involving the above tax matters to: 1 the appointee first named above, or 2 (name of another appointee designated above) E Signature of or for taxpayer(s) or principal reporting corporation. If signed by a corporate officer, partner, or fiduciary on behalf of the taxpayer, I certify that I have the authority to execute this power of attorney on behalf of the taxpayer and/or principal reporting corporation.
Massachusetts Department of Revenue. Entity and member information Completionrequired.The pass-throughentity will retainthis certificatein its recordsfor possibleinspectionby the Commissioner. Name of pass-throughentity FederalIdentificationnumber ***THIS FORM DOES NOT GET COMPLETED BY A SECTION 115 TAX EXEMPT ENTITY*** Address City/Town State Zip Name of member FederalIdentificationor Social Securitynumber Member must complete either the individual or organization certification. Check one box only.
