LGL-001Power of Attorney Taxpayer222s Name þ Social Security Number Spouse222s Name (Personal income tax or individual use tax only) þ Social Security Number Mailing Address þ Connecticut Tax Registration Number þ þ þ þ Department of Revenue Services State of Connecticut 450 Columbus Blvd Ste 1 Hartford CT 06103-1837(Rev. 01/18)Part I: Taxpayer(s) Giving a Power of Attorney to Another PersonTaxpayer is: (Check box) þ þ Corporation þ þ Partnership þ þ Sole Proprietorship þ þ Trust (other than a business trust) þ þ Estate þ þ Individual þ þ Limited Liability Company þ þ Business Trust þ þ Other (specify) þ Part II: Declaration of Person(s) Giving Power of Attorney and Powers Given The taxpayer(s) named above appoints the following individual(s) as attorney(s)-in-fact to represent the taxpayer(s) before DRS and receive tax returns and return information for the following tax matters. Specify all tax types and periods affected by this power of attorney with the understanding that this authority applies only to the tax types and periods listed below. Enter the date of death for succession and estate taxes. Indicate the representative to whom a copy of any notice from DRS should be sent by checking the box below. Check one box only. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ the Department of Revenue Services (DRS) for the same tax matters and years or periods covered by this power of attorney. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ Gen. Stat. 24712-15, and to perform on behalf of the taxpayer(s) the following acts for the tax matters described below. The authority does þ þ þ þ þ þ þ þ þ þ þ Check the boxes for the powers given to:Print Name: þ þ Title: þ Signature: þ þ Date: þ Part III: Power of Attorney Given To þ Name þ Address þ Check One Box þ Telephone Number Tax Type (Sales Tax, Gift Tax, etc.) þ þ Year(s) or Period(s) Receive, but not to endorse and collect, checks (made payable to the taxpayer mentioned above) in payment of any refund of Connecticut taxes, penalties, or interest. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ of disallowance of a claim for credit or refund.Execute or terminate consents extending the statutory period for assessment or collection of tax.Execute closing agreements under Conn. Gen. Stat. 24712-2e.Delegate authority or to substitute another representative.Represent the taxpayer(s) named above before DRS.Sign returns. (See instructions.)Declaration: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ this power of attorney on behalf of the taxpayer and I am permitted by the instructions on this Form LGL-001 to execute this power of attorney. I declare under penalty of law that I have examined this þ document (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete, and correct. þ I understand the penalty for willfully delivering a false return or document to þ DRS is a þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ ( )( ) American LegalNet, Inc. www.FormsWorkFlow.com Use LGL-001, Power of Attorney, to authorize one or more individuals to represent you before DRS. This authorization þ þ þ þ þ þ þ þ tax information and to act on your behalf in matters before DRS. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ matter of policy, DRS also provides taxpayers with the right to þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ of attorney with DRS for the type of tax and tax period that is the subject of the notice. This power of attorney does not change þ þ þ þ þ þ þ þ þ þ the taxpayer.Part I: Taxpayer(s) Giving a Power of Attorney to Another PersonProvide the taxpayer222s name and address and either your Social Security Number (SSN) or Connecticut Tax Registration Number þ þ þ þ þ þ þ þ þ þ proprietor, enter your name and SSN. Do not enter your trade name. Do not use your representative222s address as your own. Your spouse222s name is not required except for joint personal income tax or individual use tax returns. þ þ þ þ þ þ þ þ þ þ þ þ þ your spouse have the same representative(s), include your spouse222s name and SSN in the space provided. Otherwise, each þ þ þ þ þ Check the box that describes the taxpayer.Part II: Declaration of the Person Giving Power of Attorney And Powers GivenAny person giving a power of attorney to another person(s) must sign this declaration and must check the box for each act being granted to the attorney-in-fact to perform in matters before DRS. If a tax matter concerns a joint return, both husband and wife must sign in the space provided if they wish to be represented by the same person(s).Who may execute this power of attorney? þ Any individual if the request is for an income tax return þ þ þ þ þ þ þ þ þ þ þ þ her spouse if the request is for a joint income tax return); þ þ þ þ þ þ þ þ þ þ charged with the care of the person or property of the taxpayer, to make and sign a return only when illness, absence, minority, or other good cause prevents the person required or permitted to þ þ þ þ þ þ þ þ þ þ þ þ must state a reason why the taxpayer cannot sign the return. þ A limited liability company (LLC) member if the taxpayer is an LLC and has no manager or a manager if the taxpayer is an LLC and has managers þ The sole proprietor if the taxpayer is a sole proprietorship; þ A general partner if the taxpayer is a partnership or a limited partnership; þ The administrator or executor if the taxpayer is an estate; þ The trustee if the taxpayer is a trust; þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ Instructionsperson who is designated by the board of directors or other þ þ þ þ þ þ þ þ þ of the corporation upon written request signed by a principal þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ is authorized to receive or inspect the corporation222s return or return information under I.R.C. 2476103(e)(1)(D); þ The successor, receiver, guarantor, or any assignee of the taxpayer; or þ The authorized representative of any of the above.Part III: Power of Attorney Given ToProvide the name, address, and telephone number of the person(s) designated by you to be your attorney(s)-in-fact. If you are adding additional representatives to an existing power of attorney, include the names of all individuals you wish to represent you. This power of attorney revokes all previous þ þ þ þ þ þ þ þ þ þ þ þ and years or periods covered by this power of attorney. Enter the tax type and the tax periods or tax years that are the þ þ þ þ þ þ þ þ þ þ þ þ tax at issue (refer to the following examples): þ Withholding tax; þ Income tax; þ Sales and use taxes; þ Corporation business tax; þ Admissions and dues tax; þ Estate tax; þ Gift tax; þ Motor vehicle fuels tax; þ Gross earnings tax (petroleum, gas, hospital, community antenna); þ Cigarette tax distributor; and þ Individual use tax.The terms years and periods can indicate various time frames.A tax year may be a calendar year of 1/1/06 through 12/31/06 þ þ þ þ þ þ þ þ þ þ þ þ tax period may have one or more monthly or quarterly periods.Example: A sales and use tax period of 1/1/04 through 12/31/06 may contain 36 monthly or 12 quarterly periods.Indicate the tax year(s) or tax period(s) to be covered by the power of attorney.Where to FileDo not send an LGL-001 to DRS unless you have been in contact with DRS and determined that you would like a third party to represent your interests before the agency. Mail, fax, or deliver LGL-001 directly to the DRS employee or unit with whom the attorney-in-fact will interact. Consult a þ þ þ þ þ þ þ þ þ þ þ fax number where the LGL-001 should be directed. To contact DRS, call 1-800-382-9463 (Connecticut calls outside the Greater Hartford calling area only) and select Option 2 from a touch-tone þ þ þ þ þ þ þ þ þ Telephone users only may transmit inquiries anytime by calling 860-297-4911.LGL-001 (Back 01/18) American LegalNet, Inc. www.FormsWorkFlow.com