State of Connecticut
Department of Revenue Services
25 Sigourney Street
Hartford CT 06106-5032
Limited Power of Attorney
LGL-003 gives another person authority to receive blank tax returns, return information and refund checks for a taxpayer .
Who is Giving a Limited Power of Attorney to Another Person?
Taxpayer’s Name Social Security Number
Spouse’s Name Social Security Number
Street Address CT Tax Registration Number
City State Zip Code Federal Employer Identification Number
r Any individual (for an income or individual use tax return filed by that individual or a joint income tax return filed by the individual and his or her
r Corporation r Partnership r Sole Proprietorship r Trust (other than a business trust)
r Estate r Business Trust r Limited Liability Company r Other (specify)
To Whom is a Limited Power of Attorney Given?
The above-named taxpayer hereby appoints the following individual(s) as attorney(s)-in-fact to be mailed blank tax returns, return information, including
notices of assessment, billing statements, credit notices, refund checks (made payable to the above-named taxpayer), and other items that pertain to the
taxpayer and that would otherwise be mailed directly to the taxpayer.
Name Address T elephone Number
Type of Tax (Corporation Business Tax, Admissions Tax, etc.) Year(s) or Period(s)
Any of the attorney(s)-in-fact are authorized, subject to revocation, to receive blank returns and the information specified above, but are not authorized
to represent the above-named taxpayer before any division of the Department of Revenue Services (DRS). This limited power of attorney revokes all
earlier similar powers on file with DRS for the same tax matter and years or periods covered by this power of attorney.
Who May Execute This Limited Power of Attorney?
LGL-003 (Rev. 1/99)
• Any individual, if the request pertains to an income or individual use tax
return filed by that individual (or by an individual and his or her spouse
if the request pertains to a joint income tax return)
• A limited liability company (LLC) member, if the taxpayer is an LLC
that is not managed by managers, or a manager, if the taxpayer is an LLC
that is managed by managers
• The sole proprietor, if the taxpayer is a sole proprietorship
• A general partner, if the taxpayer is a partnership or a limited partnership
• The administrator or executor, if the taxpayer is an estate
• The trustee, if the taxpayer is a trust
• A principal officer, if the taxpayer is a corporation
• The successor, receiver, guarantor or assignee of the taxpayer
• The authorized representative of any of the above
I hereby declare that if I am not the taxpayer identified above, I have been authorized by that taxpayer to execute this power of attorney on behalf of
the taxpayer and I am permitted by the instructions on this form (LGL-003) to execute this power of attorney.
I understand that I am authorizing DRS to mail blank tax returns, not to the taxpayer, but to the person(s) that I have appointed in this limited power
of attorney, and I acknowledge that the taxpayer’s duty to file timely tax returns is in no way diminished.
I understand that I am authorizing DRS to mail return information, including but not limited to notices of assessment and billi ng statements, and other
correspondence, not to the taxpayer, but to the person(s) that I have appointed in this limited power of attorney. I acknowled ge that the period
within which the taxpayer is permitted to file any petition for reassessment begins to run once DRS mails the notice of assessment to the person(s)
that I have appointed in this limited power of attorney.
I declare under the penalty of false statement that I have examined this document and, to the best of my knowledge and belief it is true, correct and
complete. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two thousand dollars.)
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