CDTFA-392 (FRONT) REV. 11 (1-18) STATE OF CALIFORNIA POWER OF ATTORNEY CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION EMPLOYMENT DEVELOPMENT DEPARTMENT Check below to indicate the appropriate agency. Please note that a separate form must be completed and provided to each agency checked. CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION PO BOX 942879 SACRAMENTO, CA 94279-0001 1-800-400-7115 (TTY:711) EMPLOYMENT DEVELOPMENT DEPARTMENT PO BOX 826880 MIC 28 SACRAMENTO CA 94280-0001 1-916-654-7263 225 FAX 1-916-654-9211 TAXPAYER222S OR FEEPAYER222S NAME BUSINESS OR CORPORATION NAME TELEPHONE NUMBER ( ) FAX NUMBER ( ) SOCIAL SECURITY NUMBER FEDERAL EMPLOYER IDENTIFICATION NUMBER CALIFORNIA SECRETARY OF STATE NUMBER(S) CALIFORNIA DEPARTMENT OF TAX AND FEE ADMINISTRATION ACCOUNT/PERMIT(S) EDD EMPLOYER ACCOUNT NUMBER MAILING ADDRESS (Number and Street, City, State, ZIP Code) INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY OTHER As owner, officer, receiver, administrator, or trustee for the taxpayer or feepayer, or as a party to the tax or fee matter before the: California Department of Tax and Fee Administration Employment Development Department I hereby appoint: [enter below the individual appointee(s) name(s), address(es) (including ZIP code), telephone number(s) and fax number(s)227do not enter names of accounting or law firms, partnerships, corporations, etc., as the appointee name] APPOINTEE NAME APPOINTEE NAME APPOINTEE BUSINESS NAME (if applicable) APPOINTEE BUSINESS NAME (if applicable) APPOINTEE ADDRESS (Number and Street) APPOINTEE ADDRESS (Number and Street) (City) (State) (ZIP Code) (City) (State) (ZIP Code) TELEPHONE NUMBER () FAX NUMBER () TELEPHONE NUMBER () FAX NUMBER () As attorney(s)-in-fact to represent the taxpayer(s) or feepayer(s) for the following tax or fee matters: [specify type(s) of tax] Tax and Fee Programs Administered by CDTFA Payroll Tax Law Benefit Reporting Other: SPECIFY THE TAX OR FEE YEAR(S) OR PERIOD(S) The attorney(s)-in-fact (or any of them) are authorized, subject to revocation, to receive confidential tax information and to perform on behalf of the taxpayer(s) the following acts for the tax or fee matters described above: [check the box(es) for the powers granted] General Authorization (including all acts described below). Specific Authorization (selected acts described below). To confer and resolve any assessment, claim or collection of a deficiency or other tax or fee matter pending before the identified agency and attend any meetings or hearings thereto for the specified law identified above. To receive, but not to endorse and collect, checks in payment of any refund of taxes, penalties or interest. To execute petitions, claims for refund and/or amendments thereto. To execute consents extending the statutory period for assessment or determination of taxes. To represent the taxpayer for changes to their mailing address for any and all Payroll Tax Law, Benefit Reporting, both Payroll Tax Law and Benefit Reporting. (The back of this form must be completed) American LegalNet, Inc. www.FormsWorkFlow.com CDTFA-392 (BACK) REV. 11 (1-18) To execute settlement agreements under section 1236 of the California Unemployment Insurance Code. To delegate authority or to substitute another representative. To Other acts (specify): This Power of Attorney revokes all earlier Power(s) of Attorney on file with the California Department of Tax and Fee Administration or the Employment Development Department as identified above for the same matters and years or periods covered by this form, except for the following: [specify to whom granted, date and address, or refer to attached copies of earlier power(s)] NAME DATE POWER OF ATTORNEY GRANTED ADDRESS (Number and Street, City, State, ZIP Code) Unless limited, this Power of Attorney will remain in effect until the final resolution of all tax or fee matters specified herein. [specify expiration date if limited term] TIME LIMIT/EXPIRATION DATE (for California Department of Tax and Fee Administration purposes) Signature of Taxpayer(s) or Feepayer(s)227If a tax or fee matter concerns a joint return, both spouses must sign if joint representation is requested. If you are a corporate officer, partner, guardian, tax or fee matters partner/person, executor, receiver, registered domestic partner, administrator, or trustee on behalf of the taxpayer or feepayer, by signing this Power of Attorney you are certifying that you have the authority to execute this form on behalf of the taxpayer or feepayer. IF THIS POWER OF ATTORNEY IS NOT SIGNED AND DATED BY AN AUTHORIZED INDIVIDUAL, IT WILL BE RETURNED AS INVALID. SIGNATURE TITLE (if applicable) DATE PRINT NAME TELEPHONE () SIGNATURE TITLE (if applicable) DATE PRINT NAME TELEPHONE () American LegalNet, Inc. www.FormsWorkFlow.com