INSTRUCCIONES PARA COMPLETAR EL PODER Y DECLARACIÓN DE REPRESENTACIÓN DE MISSISSIPPI Y LA SOLICITUD DE COPIAS DE DECLARACIONES DE IMPUESTOS DE MISSISSIPPI Estamos solicitando autorización para obtener copias de las declaraciones del impuesto a las ventas y al uso del Estado de Mississippi. Se deben presentar las siguientes autorizaciones ante el Programa del Acuerdo: Poder y declaración de representación de Mississippi (Formulario 21-002-13) y la Solicitud de copias de declaraciones de impuestos de Mississippi (Formulario 70-698). Se adjuntan los formularios de autorización inmediatamente a continuación de estas instrucciones, y también se encuentran disponible en www.deepwaterhorizoneconomicsettlement.com. Cóm o com pletar el P oder y declaración de representación de M ississippi (Form ulario 21-00213). El Poder y declaración de representación de Mississippi (Formulario 21-002-13) ha sido previamente completado para autorizar al Administrador de Reclamaciones a recibir y examinar la información tributaria confidencial que especifica el contribuyente/empresa reclamante. La empresa reclamante debe completar los siguientes campos: Información del(de los) contribuyente(s). Ingrese el(los) nombre(s) del contribuyente/s, la dirección postal y el número de identificación federal del empleador (Federal Employer Identification Number, FEIN). Asunto(s) tributario(s). Número de cuenta. Ingrese el número de cuenta asociado con el contribuyente/empresa reclamante. 1. Período(s) de impuestos. Ingrese el(los) período(s) especificado(s) en la sección Explicación de la Notificación de solicitud de verificación de documentos. Asegúrese de ingresar el período usando el formato MM/DD/AAAA – MM/DD/AAAA. Actos(s) autorizado(s). Revise el archivo adjunto “Asunto: Eliminaciones del Poder (Formulario 21-00213)” y luego asegúrese de que un representante autorizado del contribuyente/empresa reclamante complete el Nombre del contribuyente, firme y feche el formulario, e indique su cargo, número de teléfono y número de fax. Retención/Revocación de Poder(es) anterior(es). Si desea que cualquier Poder(es) previamente concedido(s) permanezca(n) en vigor una vez que este Poder se presenta ante el Departamento de Hacienda de Mississippi, marque la casilla y adjunte una copia del(de los) Poder(es) correspondiente(s). Firma. Asegúrese de que un representante autorizado del contribuyente/empresa reclamante firme y feche el formulario, e indique su cargo, número de teléfono y número de fax. Cóm o com pletar la Solicitud de copias de declaraciones de im puestos de M ississippi (Formulario 70-698). 2. La Solicitud de copias de declaraciones de impuestos de Mississippi (Formulario 70-698) ha sido previamente completada con el fin de autorizar al Departamento de Hacienda de Mississippi a enviar por correo sus declaraciones del impuesto a las ventas y al uso directamente al Administrador de WWW.DEEPWATERHORIZONECONOMICSETTLEMENT.COM Página 1 de 2 Reclamaciones. La empresa reclamante debe completar los siguientes campos: Número de cuenta. Ingrese el Número de cuenta asociado con el contribuyente/empresa reclamante. Período de impuestos. Ingrese el(los) período(s) especificado(s) en la sección Explicación de la Notificación de solicitud de verificación de documentos. Asegúrese de ingresar el período usando el formato MM/DD/AAAA – MM/DD/AAAA. Firma. Asegúrese de que un representante autorizado del contribuyente/empresa reclamante indique su cargo y número de teléfono, y firme y feche el formulario en presencia de un notario público. Un notario público tendrá que completar la sección que sigue: Declaración jurada. Un notario público debe completar esta sección del formulario de autorización y certificar que el representante autorizado del contribuyente/empresa reclamante firmó el formulario y da su consentimiento para la divulgación de la información del impuesto a las ventas y al uso al Programa del Acuerdo. No es necesario que complete ninguna sección o campo del formulario que no sean los mencionados antes. NO envíe ningún pago con este formulario, el Programa del Acuerdo cubrirá todos los costos necesarios de obtención de las copias de sus declaraciones del impuesto a las ventas y al uso. Envíe el Form ulario de autorización en línea o en copia im presa. 3. Envíe el Poder y declaración de representación de Mississippi (Formulario 21-002-13), incluido el adjunto relativo a las Eliminaciones del Poder, y la Solicitud de copias de declaraciones de impuestos de Mississippi (Formulario 70-698) en línea a través de su Portal de DWH. Asegúrese de que los PDF sean de buena calidad y que no haya marcas o manchas en el documento como consecuencia de la digitalización. Además, al cargarlos, rotule el documento como “Solicitud de declaraciones de impuestos a las ventas y al uso (Mississippi)”. Como alternativa, puede enviar el formulario firmado, en copia impresa, junto con cualquier adjunto(s) exigido(s). Si desea enviar copias impresas del Poder y declaración de representación para Mississippi (Formulario 21-002-13), incluido el adjunto relativo a las Eliminaciones del Poder, y la Solicitud de copias de declaraciones de impuestos de Mississippi (Formulario 70-698), puede presentar los documentos requeridos mediante cualquiera de las siguientes maneras. Por correo (El franqueo postal no puede ser posterior a su fecha límite para dar respuesta) Por correo certificado o registrado, con entrega en 24 horas (Si lo envía por correo, debe tener sello postal dentro del plazo estipulado para responder; si es otro correo con entrega en 24 horas, debe depositarlo en custodia de un servicio de correo de entrega en 24 horas dentro del plazo estipulado para responder). Deepwater Horizon Economic Claims Center PO Box 10272 Dublin, OH 43017-5772 Deepwater Horizon Economic Claims Center c/o Claims Administrator 5151 Blazer Parkway Suite A Dublin, OH 43017 WWW.DEEPWATERHORIZONECONOMICSETTLEMENT.COM Página 2 de 2 POWER OF ATTORNEY AND DECLARATION OF REPRESENTATION Form 21-002-13 PART I POWER OF ATTORNEY For DOR Use Only Taxpayer(s) Information Taxpayer Name(s) and Mailing Address Taxpayer Social Security Number Received by: Name __________________________ Spouse Social Security Number Phone _________________________ Federal ID Number (FEIN) Date ____________________ Hereby appoint(s) the following representative(s): Representative Information Name and Mailing Address Deepwater Horizon Economic Claims Center ("DHECC") P.O. Box 10272 Dublin, OH 43017 Phone Number ( 844 ) 761-7057 _________________________________________________ FAX Number ( ) _________________________________________________ Phone Number ( ) ________________________________________________ FAX Number ( ) _________________________________________________ Phone Number ( ) _________________________________________________ FAX Number ( ) _________________________________________________ Name and Mailing Address Name and Mailing Address To represent the taxpayer(s) before the Mississippi Department of Revenue in: Tax Matter(s) Tax Type (Income, Franchise, Sales, Insurance Premium, etc.) Account Number Tax Period(s) Sales and Use Acts Authorized I (we) as the taxpayer(s) give authorization to the representative(s) to receive and inspect confidential tax information and to perform any and all acts that the taxpayer(s) can perform with respect to the matters concerning the taxes and accounts described under Tax Matter(s) above, for example, the authority to sign any agreements, consents or other documents and to represent the taxpayer(s) in any informal or formal proceeding involving the Department of Revenue. The authority of the representative(s) does not and cannot include the power to substitute another representative or to request that tax return(s) or other confidential tax information of the taxpayer(s) be inspected by or disclosed to another person. The authority also does not include the authority to receive tax refund checks or to sign returns unless specifically added below. List any specific additions or deletions to the acts otherwise authorized by this Power of Attorney: Additions: ____________________________________________________________________________________ See attachment "Re: Deletions from Power of Attorney (Form 21-002-13)" Deletions: ____________________________________________________________________________________ The Department of Revenue may reject a submission due to incompleteness, lack of specificity, or inappropriateness. DEPARTMENT OF REVENUE P.O. BOX 1033 JACKSON, MS 39215-1033 Phone: 601-923-7000 DOR Power of Attorney, Form 21-002 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 Department of Revenue for the same tax matter(s) covered by this document. If you do not want to revoke a prior Power or Attorney, check here and ATTACH A COPY OF THE POWER(S) OF ATTORNEY YOU WANT TO REMAIN IN EFFECT. Who Must Sign and What Documentation of Authority Must Be Attached If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested. A corporation or subsidiary MUST contain the signatures of a principal officer and the secretary or other officer. A guardian, executor, receiver, administrator, conservator or trustee MUST attach the appropriate documentation granting the authority from the court or taxpayer. Signing is Certification Under Oath Subject to Penalty of Perjury The person(s) signing this Power of Attorney and Declaration of Representations certifies under oath that all the information contained in this document is true and correct and that he, she or they have the authority to sign this document as the taxpayer(s) or on behalf of the taxpayer(s) and acknowledge that this Power of Attorney and Declaration of Representation is being signed under the penalty of perjury pursuant to Miss. Code Ann. § 27-3-83(5). IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED. Signature Date Title (if applicable) Print Name Phone Number FAX Number Signature Date Title (if applicable) Print Name Phone Number FAX Number PART II DECLARATION OF REPRESENTATIVE Under penalties of perjury and Miss. Code Ann. §97-7-10, I declare that: 1) I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there: and 2) 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 authorized to practice as a certified public accountant in the jurisdiction shown. c. Officer – a bona fide officer of the taxpayer’s organization. d. Full-time employee – a full time employee of the taxpayer. e. Family Member – a member of the taxpayer’s immediate family (i.e., spouse, parent, child, brother, or sister). f. Enrolled Agent – enrolled as an agent under the requirements of the IRS. Director of DHECC-Fraud, Waste and Abuse to whom taxpayer wishes to release tax records g. Other – Provide explanation ________________________________________________________________ IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED. Designation – Insert Above letter (a-g) State Issuing License State License Number N/A N/A g DEPARTMENT OF REVENUE P.O. BOX 1033 Signature JACKSON, MS 39215-1033 Date Phone: 601-923-7000 Mississippi Department of Revenue P.O. Box 1033 Jackson, MS 39215-1033 RE: Deletions from Power of Attorney (Form 21-002-13) Taxpayer Name(s): _____________________________________________________________ I (we) as the taxpayer(s) do not authorize the representative, Deepwater Horizon Economic Claims Center, to perform the following acts that would otherwise be authorized by this Power of Attorney: To perform any and all acts that the taxpayer(s) can perform with respect to the matters concerning the taxes and accounts described under Tax Matter(s), for example, the authority to sign any agreements, consents or other documents and to represent the taxpayer(s) in any informal or formal proceeding involving the Department of Revenue. ______________________________ ________________ _____________________ ______________________________ ________________ _____________________ ______________________________ ________________ _____________________ ______________________________ ________________ _____________________ Signature Print Name Signature Print Name Date Phone Number Date Phone Number Title (if applicable) FAX Number Title (if applicable) FAX Number REQUEST FOR COPIES OF TAX RETURNS Form 70-698 Request may be rejected if the form is incomplete, illegible or any required line was blank. Payment must be made prior to issuing copies. You may contact the Department of Revenue at 601 923-7000 and ask for the Tax Area responsible for the administration of the tax type you are requesting copies from to determine how many pages your request will generate. This will determine the cost. The Account Number is the Social Security Number (SSN) for Individual Income Tax, the Federal Employer’s Identification Number (FEIN) for Corporate Income Tax and Withholding Tax, and the Sales and/or Use Tax Account Number for most other tax types. For Individual Income Tax Returns that are filed jointly, both spouses SSNs and names are required before copies can be released. sales and use ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________ TAX PERIOD: ____________________ sales and use ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________ TAX PERIOD: ____________________ sales and use ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________ TAX PERIOD: ____________________ sales and use ACCOUNT NUMBER: ______________________ TAX TYPE: ____________________ TAX PERIOD: ____________________ Name and address where to send the copies of the requested returns. If you want these copies certified, please check here. Name: Deepwater Horizon Economic Claims Center _____________________________________________________________________________________ Address: P.O. Box 10272 _____________________________________________________________________________________ City, State, Zip: Dublin, OH 43017-5772 _____________________________________________________________________________________ Phone Number: 844-761-7057 _____________________________________________________________________________________ The “Mississippi Public Records Act of 1983” requires the following charges be submitted before delivery of the reproduced documents. Payments must be in the form of cash, a cashier’s check or money order. We do not accept personal checks for copies. We do not recommend you send cash through the mail. The charge for copies is $2.50 for the first page and $.50 for each additional page. We will return this document with the charge on it. Please allow 7 days for processing. Contact this office at 601-923-7000 to determine the cost of the copies. Ask for the Tax Area responsible for the tax type of the return you have requested. Signature of Taxpayer(s): Under penalties of perjury, I declare that I am either the taxpayer whose name is shown above or a person authorized to obtain the tax return requested. If the request applies to a joint return, either spouse can sign. If signed by a corporate officer, partner, guardian, executor, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer. Taxpayer Signature: ______________________________________________________ Date: ___________________ Spouse Signature: _________________________________________________________________________________ Title if officer, partner, trustee or party other than taxpayer: _________________________________________________________ Contact Phone Number: _____________________________________________________________________________________ AFFIDAVIT STATE OF __________________________________ COUNTY OF _____________________________________ Before me, the undersigned authority, on this day personally appeared ________________________________________________, known to me to be the person whose name is subscribed to the foregoing authorization and who, after being by me duly sworn, upon oath states that same was executed for the purpose therein expressed. SUBSCRIBED and SWORN to me, a Notary Public, on the _______________ day of ____________________________, 20______. My Commission Expires:_______________________________ ________________________________________________ Notary Public NUMBER OF PAGES COPIED: ___________ TOTAL COST: $___________ DATE PAYMENT RECEIVED: ________________ INITIAL AND DATE WHEN RETURNS WERE COPIED AND SENT: ____________________________________________________