rom 2048 Power of Attorney and

(Rev. April 1986) i i OMB No. 1545-0150
“ ; Declaration of Representative OMB No. 1548.0
Intbrel Revonue Semmes > See separate instructions.
Power of Attorney For IRS Use Only

B | Texpayer(s) name(s) Identification number File So.

5 Level

: Receipt

g ‘Address (Number and street) Plan number (if applicable) Powers

g Blind T.

F City, state, and ZIP code Action |

3 Ret. Ind I
hereby appoint(s) the following individual(s)*

Name CAF No. ‘Address Telephone No.

as attorney(s)-in-fact to represent the taxpayer(s) before any office of the Internal Revenue Service for the following tax matter(s) (specify
the type(s) of tax and year(s) or period(s) (date of death if estate tax))

Type of tax formmumber Year(s) or period(s)
(Individual, corporate, etc.) (1040, 1120, etc.) (Date of death if estate tax)

The attorney(s)-in-fact (or either of them) are authorized, subject 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 (excluding the power to receive refund checks and
the power to sign the return, unless specifically granted below). See Regulations section 1.6012-1(a)(5) for information on returns made
by agents.

D Send originals of all notices and all other written communications in proceedings involving the above tax matters to the appointee first
named above, and a duplicate copy of all notices and all other written communications to the taxpayer named above, or

O send copies of all notices and all other written communications addressed to the taxpayer(s) in proceedings involving the above tax
matters to:

1 (1 the appointee first named above, or
2 © (names of not more than two of the appointees named above)

Initialherem _.. 2222. if you are granting the power to receive, but not to endorse or cash, refund checks for the
above tax matters to :

3 ( the appointee first named above, or
40 (name of one of the above designated appointees) > _............--2- 2-22-2222 e cece eee eee eee eee eee eee eee eee

This power of attorney revokes all earlier powers of attorney and tax information authorizations on file with the Internal Revenue Service for
the same tax matters and years or periods covered by this power of attorney, except the following:

(Specify to whom granted, date, and address including ZIP code, or refer to attached copies of earlier powers and authorizations.)

Signature of or for taxpayer(s)

(If signed by a corporate officer, partner, or fiduciary on behalf of the taxpayer, | certify that | have the authority to execute this power of
attorney on behalf of the taxpayer.)

(Also type or print your name below if signing for a taxpayer who 1s not an individual.)

(Signature) Citie, ifappiicable) (Date)

* You may authorize an organization, firm, or partnership to receive confidential information, but your representative must be an individual who must complete Part Il
For Privacy Act and Paperwork Reduction Act Notices, see page 1 of the separate instructions. Form 2848 (Rev. 4-86)



Form 2848 (Rev. 4-86) Page 2

If the power of atterney is granted to a person other than an attorney, certified public accountant, enrolled agent, or enrolled actuary, the
taxpayer(s) signature must be witnessed or notarized below. (The representative must complete Part Il. List representatives there only if
they are recognized to practice before the Internal Revenue Service.)

The person(s) signing as or for the taxpayer(s): (Check and complete one.)
Oo is/are known te and signed in the presence of the two disinterested witnesses whose signatures appear here:

(Signature of Witness) (Date)

(Signature of Witness) . ~ (Batey ~

Cappeared this day before a notary public and acknowledged this power of attorney as a voluntary act and deed.

Witness: NOTARIAL SEAL

(Signature of Notary) (Date) (if required by state law)

Declaration of Representative

{declare that | am not currently under suspension or disbarment from practice before the Internal f Revenue Service, that | am aware of
Treasury Department Circular No. 230 (31 CFR, Part 10), as amended, regulations governing the practice of attorneys, certified public
accountants, enrolled agents, enrolled actuaries, and others, and that | am one of the following

a member in good standing of the bar of the highest court of the jurisdiction shown below;
duly qualified to practice as a certified public accountant in the jurisdiction shown below;
enrolled as an agent under the requirements of Treasury Department Circular No. 230;

a bona fide officer of the taxpayer organization;

a full-time employee of the taxpayer;

a member of the taxpayer's immediate family (spouse, parent, child, brother or sister);

a fiduciary for the taxpayer;

an enrolled actuary (the authority of an enrolled actuary to practice before the Service s limited by section 10.3(d)(1) of
Treasury Department Circular No. 230);

9 Commissioner's special authorization (see instructions for Part lI, item 9)

ONanuewne

and that | am authorized to represent the taxpayer identified in Part | for the tax matters specified there.

, a

Designation Jurisdiction |
(insert appropriate number (state, etc.) Signature Date
from above list) or Enrollment Card Number

U.S. GOVERNMENT PRINTING OFPTCE:1986-493-305 F.1. NC. 43-1409716