Limited Power of Attorney Example - Wyoming

DAVE FREUDENTHAL, Governor
E
DMUND J. SCHMIDT, Director
State of Wyoming
DEPARTMENT OF REVENUE
122 West 25th Street, 2-West, Cheyenne, Wyoming 82002-0110
Telephone: (307) 777-7961 Web:http://revenue.state.wy.us E-mail:dor@wy.gov
Administration Fax (307)777-7722 Ad Valorem Division Fax (307)777-7722 Excise Division Fax (307)777-3632 Mineral Division Fax (307)777-7849 Liquor Division Fax (307)777-6255
Effective 09/23/04
ETS Form 150
Excise Tax Division
Limited Power of Attorney
Sales/Use Tax License Number:
Revenue Identification Number:
Business’/Owner’s/Taxpayer’s Name:
Mailing Address:
TO WHOM IT MAY CONCERN: I/We have appointed
as our agent to represent the above mentioned taxpayer before the Wyoming Excise Tax
Department for the following excise tax matters until further notice:
Tax Type (Sales, Use, Estate,
Cigarette, etc.)
Document Requested (Tax returns - specify
form #, written determinations, notices, etc.)
Year(s) or
Period(s)
I declare under penalty of perjury that I have the authority to sign this limited power of attorney
for the above mentioned taxpayer:
Authorized by: Title:
(Individual Business – Owner; Corporation – Major Officer;
Partnership – Partner; LLC or LLP – Member or Manager)
Phone Number: Date:
The foregoing document was acknowledged before me by
this day of , 20 .
Witness my hand and official seal,
(Notary Public). My commission expires .
Return signed original to: Wyoming Department of Revenue For questions, please call:
Excise Tax Division, Herschler Bldg.
122 W. 25
th
St., 2
nd
Floor West
Cheyenne, WY 82002-0110
307-777-5200
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