Form R-7006 Fillable Power of Attorney and Declaration of Representative
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

Corporate income/franchise tax Gasoline tax Individual income tax Other (Please specify ) Sales and use tax Sign the return(s) for the above tax matters Special Fuels tax Tobacco tax Withholding tax (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (insert applicable letter in table below) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) a Attorney a member in good standing of the highest court of the jurisdiction shown below Above Letter (a h) Acts Authorized Mark only the boxes that apply By marking the boxes you authorize the representative to perform any and all acts on and to perform any and all acts that I/we can perform with respect to my/our tax matters unless noted below Modes of communication authorized b Certified Public Accountant duly qualified to practice as a certified public accountant in the jurisdiction shown below before c Enrolled Agent a person enrolled to practice before the Internal Revenue Service City/State/ZIP currently d Officer a bona fide officer of the taxpayer organization DELETIONS Mark or list any specific deletions to the acts otherwise authorized in this power of attorney Department of Revenue The representative is authorized to receive and inspect confidential information concerning my/our tax matters Designation Insert disbarment e Employee an employee of the taxpayer E mail address Execute an agreement to suspend prescription of tax Execute offers in compromise or settlements of tax liability f Family Member a member of the taxpayer s immediate family (state the relationship i e spouse parent child brother or sister) Fax number File a protest to a proposed assessment following: for requesting and receiving information may include telephone e mail or fax The authority does not include the power to g Other (state the relationship i e bookkeeper or friend) h Former Louisiana Department of Revenue Employee As a representative I cannot accept representation in a matter with which I had direct involvement while I was a public employee I/we appoint the following representative as my/our true and lawful agent and attorney in fact to represent me/us before the Louisiana identified If signed by a corporate officer partner guardian tax matters partner executor receiver administrator or trustee on behalf of the tax IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED THE POWER OF ATTORNEY WILL BE RETURNED IF THIS POWER OF ATTORNEY IS NOT SIGNED AND DATED IT WILL BE RETURNED Internal is a corporation partnership executor or administrator Issuing License matters may request and receive information by telephone e mail or fax Upon request the representative may be provided with a copy of a notice NOTICES AND COMMUNICATIONS Original notices and other written communications will be sent only to you the taxpayer Your representative Obtain a private letter ruling on behalf of the taxpayer of Representative of Revenue for the same tax matters and years or periods covered by this document or communication sent to you If you want the representative to request and receive a copy of notices and communications sent to you check Other prohibited acts (List prohibited acts ) PART I POWER OF ATTORNEY Part II DECLARATION OF REPRESENTATIVE payer I certify that I have the authority to execute this form on behalf of the taxpayer Power of Attorney and Declaration practice R 7006 (1/11) R 7006 (1/11) Page 2 R 7006 (1/11) the filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Louisiana Department receive refund checks the power to substitute another representative the power to add additional representatives or the power represent Represent the taxpayer before the department in any proceeding including protest hearings Representative must sign and date this form on page 2 Part II Revenue REVOCATION OF PRIOR POWER(S) OF ATTORNEY Except for Power(s) of Attorney and Declaration of Representative(s) filed on Form Service Signature of duly authorized representative if the taxpayer Title Signature of Taxpayer(s) If a tax matter concerns a joint return both husband and wife must sign if joint representation is requested Social Security/Louisiana or Federal ID Number specified Spouse s name if a joint return (or corporate officer partner or fiduciary if a business) Spouse s Social Security Number (if a joint return) Spouse signature State State License Number Signature Date Street address suspension Tax Type Year(s) or Period(s) Tax Type Year(s) or Period(s) Taxpayer signature taxpayer(s) Taxpayer(s) must sign and date this form on page 2 PLEASE TYPE OR PRINT Telephone number there; this box to execute a request for disclosure of tax returns or return information to a third party under Under penalties of perjury I declare that: your behalf including the authority to sign tax returns with respect only to the indicated tax matters: Your Name or Name of Entit y