Formulario de autorización e instrucciones para la información

INSTRUCCIONES PARA COMPLETAR EL
PODER Y DECLARACIÓN DE REPRESENTACIÓN DE MISSISSIPPI Y LA SOLICITUD DE COPIAS DE
DECLARACIONES DE IMPUESTOS DE MISSISSIPPI
Estamos solicitando autorización para obtener copias de las declaraciones del impuesto a las ventas y al uso del
Estado de Mississippi. Se deben presentar las siguientes autorizaciones ante el Programa del Acuerdo: Poder y
declaración de representación de Mississippi (Formulario 21-002-13) y la Solicitud de copias de declaraciones de
impuestos de Mississippi (Formulario 70-698). Se adjuntan los formularios de autorización inmediatamente a
continuación
de
estas
instrucciones,
y
también
se
encuentran
disponible
en
www.deepwaterhorizoneconomicsettlement.com.
Cóm o com pletar el P oder y declaración de representación de M ississippi (Form ulario 21-00213).
El Poder y declaración de representación de Mississippi (Formulario 21-002-13) ha sido previamente
completado para autorizar al Administrador de Reclamaciones a recibir y examinar la información tributaria
confidencial que especifica el contribuyente/empresa reclamante. La empresa reclamante debe completar
los siguientes campos:
Información del(de los) contribuyente(s). Ingrese el(los) nombre(s) del contribuyente/s, la dirección
postal y el número de identificación federal del empleador (Federal Employer Identification Number, FEIN).
Asunto(s) tributario(s).
Número de cuenta. Ingrese el número de cuenta asociado con el contribuyente/empresa reclamante.
1.
Período(s) de impuestos. Ingrese el(los) período(s) especificado(s) en la sección Explicación de la
Notificación de solicitud de verificación de documentos. Asegúrese de ingresar el período usando el formato
MM/DD/AAAA – MM/DD/AAAA.
Actos(s) autorizado(s). Revise el archivo adjunto “Asunto: Eliminaciones del Poder (Formulario 21-00213)” y luego asegúrese de que un representante autorizado del contribuyente/empresa reclamante
complete el Nombre del contribuyente, firme y feche el formulario, e indique su cargo, número de teléfono
y número de fax.
Retención/Revocación de Poder(es) anterior(es). Si desea que cualquier Poder(es) previamente
concedido(s) permanezca(n) en vigor una vez que este Poder se presenta ante el Departamento de
Hacienda de Mississippi, marque la casilla y adjunte una copia del(de los) Poder(es) correspondiente(s).
Firma. Asegúrese de que un representante autorizado del contribuyente/empresa reclamante firme y
feche el formulario, e indique su cargo, número de teléfono y número de fax.
Cóm o com pletar la Solicitud de copias de declaraciones de im puestos de M ississippi (Formulario
70-698).
2.
La Solicitud de copias de declaraciones de impuestos de Mississippi (Formulario 70-698) ha sido
previamente completada con el fin de autorizar al Departamento de Hacienda de Mississippi a enviar por
correo sus declaraciones del impuesto a las ventas y al uso directamente al Administrador de
WWW.DEEPWATERHORIZONECONOMICSETTLEMENT.COM
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Reclamaciones. La empresa reclamante debe completar los siguientes campos:
Número de cuenta. Ingrese el Número de cuenta asociado con el contribuyente/empresa reclamante.
Período de impuestos. Ingrese el(los) período(s) especificado(s) en la sección Explicación de la
Notificación de solicitud de verificación de documentos. Asegúrese de ingresar el período usando el formato
MM/DD/AAAA – MM/DD/AAAA.
Firma. Asegúrese de que un representante autorizado del contribuyente/empresa reclamante indique su
cargo y número de teléfono, y firme y feche el formulario en presencia de un notario público.
Un notario público tendrá que completar la sección que sigue:
Declaración jurada. Un notario público debe completar esta sección del formulario de autorización y
certificar que el representante autorizado del contribuyente/empresa reclamante firmó el formulario y da su
consentimiento para la divulgación de la información del impuesto a las ventas y al uso al Programa del
Acuerdo.
No es necesario que complete ninguna sección o campo del formulario que no sean los mencionados antes.
NO envíe ningún pago con este formulario, el Programa del Acuerdo cubrirá todos los costos necesarios de
obtención de las copias de sus declaraciones del impuesto a las ventas y al uso.
Envíe el Form ulario de autorización en línea o en copia im presa.
3.
Envíe el Poder y declaración de representación de Mississippi (Formulario 21-002-13), incluido el adjunto
relativo a las Eliminaciones del Poder, y la Solicitud de copias de declaraciones de impuestos de Mississippi
(Formulario 70-698) en línea a través de su Portal de DWH. Asegúrese de que los PDF sean de buena
calidad y que no haya marcas o manchas en el documento como consecuencia de la digitalización.
Además, al cargarlos, rotule el documento como “Solicitud de declaraciones de impuestos a las ventas y al
uso (Mississippi)”. Como alternativa, puede enviar el formulario firmado, en copia impresa, junto con
cualquier adjunto(s) exigido(s).
Si desea enviar copias impresas del Poder y declaración de representación para Mississippi
(Formulario 21-002-13), incluido el adjunto relativo a las Eliminaciones del Poder, y la Solicitud de
copias de declaraciones de impuestos de Mississippi (Formulario 70-698), puede presentar los
documentos requeridos mediante cualquiera de las siguientes maneras.
Por correo
(El franqueo postal no puede ser posterior a su fecha límite
para dar respuesta)
Por correo certificado o registrado, con
entrega en 24 horas
(Si lo envía por correo, debe tener sello postal dentro del plazo
estipulado para responder; si es otro correo con entrega en 24
horas, debe depositarlo en custodia de un servicio de correo de
entrega en 24 horas dentro del plazo estipulado para
responder).
Deepwater Horizon Economic Claims Center
PO Box 10272
Dublin, OH 43017-5772
Deepwater Horizon Economic Claims Center
c/o Claims Administrator
5151 Blazer Parkway Suite A
Dublin, OH 43017
WWW.DEEPWATERHORIZONECONOMICSETTLEMENT.COM
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POWER OF ATTORNEY
AND
DECLARATION OF REPRESENTATION
Form 21-002-13
PART I POWER OF ATTORNEY
For DOR Use Only
Taxpayer(s) Information
Taxpayer Name(s) and Mailing Address
Taxpayer Social Security Number
Received by:
Name __________________________
Spouse Social Security Number
Phone _________________________
Federal ID Number (FEIN)
Date ____________________
Hereby appoint(s) the following representative(s):
Representative Information
Name and Mailing Address
Deepwater Horizon Economic Claims Center ("DHECC")
P.O. Box 10272
Dublin, OH 43017
Phone Number
( 844 )
761-7057
_________________________________________________
FAX Number
(
)
_________________________________________________
Phone Number
(
)
________________________________________________
FAX Number
(
)
_________________________________________________
Phone Number
(
)
_________________________________________________
FAX Number
(
)
_________________________________________________
Name and Mailing Address
Name and Mailing Address
To represent the taxpayer(s) before the Mississippi Department of Revenue in:
Tax Matter(s)
Tax Type (Income, Franchise, Sales, Insurance Premium, etc.)
Account Number
Tax Period(s)
Sales and Use
Acts Authorized
I (we) as the taxpayer(s) give authorization to the representative(s) to receive and inspect confidential tax information and
to perform any and all acts that the taxpayer(s) can perform with respect to the matters concerning the taxes and
accounts described under Tax Matter(s) above, for example, the authority to sign any agreements, consents or other
documents and to represent the taxpayer(s) in any informal or formal proceeding involving the Department of Revenue.
The authority of the representative(s) does not and cannot include the power to substitute another representative or to
request that tax return(s) or other confidential tax information of the taxpayer(s) be inspected by or disclosed to another
person. The authority also does not include the authority to receive tax refund checks or to sign returns unless
specifically added below.
List any specific additions or deletions to the acts otherwise authorized by this Power of Attorney:
Additions: ____________________________________________________________________________________
See attachment "Re: Deletions from Power of Attorney (Form 21-002-13)"
Deletions: ____________________________________________________________________________________
The Department of Revenue may reject a submission due to incompleteness, lack of specificity, or inappropriateness.
DEPARTMENT OF REVENUE
P.O. BOX 1033
JACKSON, MS 39215-1033
Phone: 601-923-7000
DOR Power of Attorney, Form 21-002
Retention/Revocation of Prior Power(s) of Attorney
The filing of this Power of Attorney automatically revokes all earlier Power(s) of Attorney on file with the Department of
Revenue for the same tax matter(s) covered by this document. If you do not want to revoke a prior Power or Attorney,
check here
and ATTACH A COPY OF THE POWER(S) OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.
Who Must Sign and What Documentation of Authority Must Be Attached
If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested. A corporation
or subsidiary MUST contain the signatures of a principal officer and the secretary or other officer. A guardian, executor,
receiver, administrator, conservator or trustee MUST attach the appropriate documentation granting the authority from the
court or taxpayer.
Signing is Certification Under Oath Subject to Penalty of Perjury
The person(s) signing this Power of Attorney and Declaration of Representations certifies under oath that all the
information contained in this document is true and correct and that he, she or they have the authority to sign this
document as the taxpayer(s) or on behalf of the taxpayer(s) and acknowledge that this Power of Attorney and Declaration
of Representation is being signed under the penalty of perjury pursuant to Miss. Code Ann. § 27-3-83(5).
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
Signature
Date
Title (if applicable)
Print Name
Phone Number
FAX Number
Signature
Date
Title (if applicable)
Print Name
Phone Number
FAX Number
PART II DECLARATION OF REPRESENTATIVE
Under penalties of perjury and Miss. Code Ann. §97-7-10, I declare that:
1) I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there: and
2) I am one of the following:
a. Attorney – a member in good standing of the bar of the highest court of the jurisdiction shown below.
b. Certified Public Accountant – duly authorized to practice as a certified public accountant in the jurisdiction shown.
c. Officer – a bona fide officer of the taxpayer’s organization.
d. Full-time employee – a full time employee of the taxpayer.
e. Family Member – a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister).
f. Enrolled Agent – enrolled as an agent under the requirements of the IRS.
Director of DHECC-Fraud, Waste and Abuse to whom taxpayer wishes to release tax records
g. Other – Provide explanation ________________________________________________________________
IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
Designation – Insert
Above letter (a-g)
State Issuing
License
State License
Number
N/A
N/A
g
DEPARTMENT OF REVENUE
P.O. BOX 1033
Signature
JACKSON, MS 39215-1033
Date
Phone: 601-923-7000
Mississippi Department of Revenue
P.O. Box 1033
Jackson, MS 39215-1033
RE:
Deletions from Power of Attorney (Form 21-002-13)
Taxpayer Name(s): _____________________________________________________________
I (we) as the taxpayer(s) do not authorize the representative, Deepwater Horizon Economic
Claims Center, to perform the following acts that would otherwise be authorized by this Power
of Attorney:
To perform any and all acts that the taxpayer(s) can perform with
respect to the matters concerning the taxes and accounts described
under Tax Matter(s), for example, the authority to sign any
agreements, consents or other documents and to represent the
taxpayer(s) in any informal or formal proceeding involving the
Department of Revenue.
______________________________
________________
_____________________
______________________________
________________
_____________________
______________________________
________________
_____________________
______________________________
________________
_____________________
Signature
Print Name
Signature
Print Name
Date
Phone Number
Date
Phone Number
Title (if applicable)
FAX Number
Title (if applicable)
FAX Number
REQUEST FOR COPIES OF TAX RETURNS
Form 70-698
Request may be rejected if the form is incomplete, illegible or any required line was blank. Payment must be made prior to issuing copies. You may contact the Department of
Revenue at 601 923-7000 and ask for the Tax Area responsible for the administration of the tax type you are requesting copies from to determine how many pages your request will
generate. This will determine the cost. The Account Number is the Social Security Number (SSN) for Individual Income Tax, the Federal Employer’s Identification Number (FEIN) for
Corporate Income Tax and Withholding Tax, and the Sales and/or Use Tax Account Number for most other tax types. For Individual Income Tax Returns that are filed jointly, both
spouses SSNs and names are required before copies can be released.
sales and use
ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________
TAX PERIOD: ____________________
sales and use
ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________
TAX PERIOD: ____________________
sales and use
ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________
TAX PERIOD: ____________________
sales and use
ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________
TAX PERIOD: ____________________
Name and address where to send the copies of the requested returns. If you want these copies certified, please check here.
Name:
Deepwater Horizon Economic Claims Center
_____________________________________________________________________________________
Address:
P.O. Box 10272
_____________________________________________________________________________________
City, State, Zip:
Dublin, OH 43017-5772
_____________________________________________________________________________________
Phone Number:
844-761-7057
_____________________________________________________________________________________
The “Mississippi Public Records Act of 1983” requires the following charges be submitted before delivery of the reproduced documents. Payments
must be in the form of cash, a cashier’s check or money order. We do not accept personal checks for copies. We do not recommend you send
cash through the mail. The charge for copies is $2.50 for the first page and $.50 for each additional page. We will return this document with
the charge on it. Please allow 7 days for processing. Contact this office at 601-923-7000 to determine the cost of the copies. Ask for the Tax Area
responsible for the tax type of the return you have requested.
Signature of Taxpayer(s): Under penalties of perjury, I declare that I am either the taxpayer whose name is shown above or a person authorized
to obtain the tax return requested. If the request applies to a joint return, either spouse can sign. If signed by a corporate officer, partner, guardian,
executor, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.
Taxpayer Signature: ______________________________________________________ Date: ___________________
Spouse Signature: _________________________________________________________________________________
Title if officer, partner, trustee or party other than taxpayer: _________________________________________________________
Contact Phone Number: _____________________________________________________________________________________
AFFIDAVIT
STATE OF __________________________________
COUNTY OF _____________________________________
Before me, the undersigned authority, on this day personally appeared ________________________________________________,
known to me to be the person whose name is subscribed to the foregoing authorization and who, after being by me duly sworn, upon
oath states that same was executed for the purpose therein expressed.
SUBSCRIBED and SWORN to me, a Notary Public, on the _______________ day of ____________________________, 20______.
My Commission Expires:_______________________________
________________________________________________
Notary Public
NUMBER OF PAGES COPIED: ___________ TOTAL COST: $___________
DATE PAYMENT RECEIVED: ________________
INITIAL AND DATE WHEN RETURNS WERE COPIED AND SENT: ____________________________________________________