1350 STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE Part I 1 SC2848 (Rev. 12/1/11) 3307 Power of Attorney * (Note: Taxpayer(s) must sign and date this form on page 2, line 8.) Taxpayer Information Social Security number(s) Taxpayer name(s) and address (Type or print.) * * Employer identification number Plan number ( if applicable) * Daytime telephone number ( ) hereby appoint(s) the following representative(s) as attorney(s) - in fact: Email Address 2 Representative(s) (Type or print.) Name and address of specific individual * * Telephone No. ( Fax No. ( ) Check if new: Name and address of specific individual Telephone No. ( Fax No. ( ) Check if new: Name and address of specific individual Telephone No. ( Fax No. ( Check if new: to represent the taxpayer(s) before the SC Department of Revenue for the following tax matters: ) ) Address Telephone No. ) Address Telephone No. ) Address Telephone No. 3 Tax Matters - A general reference to "All years," "All periods," or "All taxes" is not acceptable. Year(s) or Period(s) * Type of Tax (Individual, Corporate, Withholding, Sales, etc.) * Tax Form Number (SC1040, WH1605, ST-3, etc.) * (See Line 3 instructions) 4 Acts Authorized - A representative is an individual authorized to receive and inspect confidential tax information and to perform any and all acts on behalf of the taxpayer with respect to the tax matters described in line 3, including the authority to sign any agreements, consents or other documents. You may not use a Power of Attorney form to authorize a representative to receive refund checks. You may authorize a representative to sign a return ONLY as set forth in South Carolina Code Section 12-2-75. List any specific additions to or deletions from the acts otherwise authorized in this power of attorney: 5 Receipt of Refund Checks - If you want to authorize a representative named in line 2 to receive, BUT NOT TO ENDORSE OR CASH refund checks, initial here and list the name of that representative below. Name of representative to receive refund check(s) 33071028 American LegalNet, Inc. www.FormsWorkFlow.com 6 Retention/Revocation of Prior Power(s) of Attorney - The filing of this power of attorney automatically revokes all earlier power(s) of attorney on file with the South Carolina Department of Revenue for the same tax matters for years or periods covered by this document . If you do not want to revoke a prior power of attorney, check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT. 7 Signature of Taxpayer(s) - If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested; otherwise, see the instructions for SC2848 concerning signature of taxpayer(s). If signed by a corporate officer, partner, guardian, tax matters partner/person, LLC members, executor, receiver, personal representative, or trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer. The Department will not accept a Power of Attorney that is not signed. * * Signature Print Name * Date Title (if applicable) Signature Date Title (if applicable) Print Name NOTICES AND COMMUNICATIONS All Notices and Communications will be sent to the taxpayer only. However, if you are unable to forward a copy to your named representative, you may contact our office for assistance. Part II Declaration of Representative I declare that: I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified; and I am one of the following: a Attorney - a member in good standing of the bar of the highest court of the jurisdiction shown below. b Certified Public Accountant - duly qualified to practice as a certified public accountant in the jurisdiction shown below. c Enrolled Agent - enrolled as an agent under the Requirements of the US Treasury Department Circular No. 230. d Officer - a bona fide officer of the taxpayer organization. e Full-Time Employee - a full-time employee of the taxpayer. f Family Member - a member of the taxpayer's immediate family (i.e., spouse, parent, child, brother, or sister). g Return Preparer. h Other, please explain. The Department will not accept a Declaration of Representative that is not signed. I declare that this return and all attachments are true, correct and complete to the best of my knowledge and belief. To wilfully furnish a false or fraudulent statement to the Department is a crime. Insert * Designation - (a-h) * Jurisdiction (state) above letter * Signature * Date * indicates required field. 33072026 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for SC2848 General Instructions Purpose of Form Use SC2848 to grant authority to an individual to represent you before the South Carolina Department of Revenue and to receive tax information. See the instructions for Part I, line 4 for limitations that may apply for certain representatives. A fiduciary (trustee, executor, administrator, receiver, or guardian) stands in the position of a taxpayer and acts as the taxpayer. Therefore, a fiduciary does not act as a representative and should not file a power of attorney. If a fiduciary wishes to authorize an individual to represent or perform certain acts on behalf of the entity, a power of attorney must be filed and signed by the fiduciary acting in the position of the taxpayer. Authority Granted This power of attorney authorizes the individual(s) named to perform any and all acts you can perform, such as signing consents extending the time to assess tax, recording the interview, or executing waivers agreeing to a tax adjustment. However, authorizing someone as your power of attorney does not relieve you of your tax obligations. Delegating authority or substituting another representative must be specifically stated on line 4. However, the authority granted to a power of attorney may not exceed that allowed under SC Code Section 12-60-90. See South Carolina Revenue Procedures 92-4 and 92-6. The power to sign tax returns can only be granted in limited situations. See Line 4 - Acts authorized for more information. Filing the Power of Attorney File the original or a photocopy or facsimile transmission (fax) with the applicable office (main or taxpayer service center). The applicable office is the office from which you request information or before which a ma