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Get FL HSMV 96440 2017

HSMV 96440 06/11 Page 2 Federal Identification Number Section 6. Signature of Registrant/Licensee The Power of Attorney is not valid until it is signed and dated by the Registrant/Licensee. Division of Motorist Services Bureau of Commercial Vehicle and Driver Services POWER OF ATTORNEY and Declaration of Representative DMS USE ONLY A photocopy of the Registrant s Driver License must be submitted with this Power of Attorney. PART 1 POWER OF ATTORNEY Section 1. Registrant/Licensee Information* Registrant/Licensee must sign and date this form in section 1 and section 6. See Page 2 Section 6 Registrant/Licensee Name and Address as shown on Cab Card or IFTA License Signature of Applicant Print Name Federal ID No* s SSN FEIN etc Registrant Telephone Number Fax Number Hereby appoints the following representative as attorney-in-fact Section 2. Representative. Representative must sign and date this form* See Page 2 Part II Name and Address of person or company being appointed as Power of Attorney. Include name of firm if applicable Telephone Number If appointed representative is a company a separate letter must be attached indicating those employees authorized to sign on behalf of the company. Letter must include signature of all authorized signers. Email Address To represent the Registrant/Licensee before the Florida Department of Highway Safety and Motor Vehicles related to the following International Registration Plan IRP and/or International Fuel Tax Agreement IFTA accounts. Section 3. Accounts Account Numbers Account Name IRP Acct* No* / Fleet No* s IFTA Acct* No* Section 4. Acts Authorized The representative s are authorized to receive and inspect confidential IRP/IFTA information and to perform any and all acts that I we can perform with respect to the accounts described in Section 3. Except as otherwise provided the authority specifically includes the power to file IRP and IFTA applications receive IRP and IFTA credentials file IFTA tax returns including claims for refunds represent the Registrant/Licensee in audit and/or collection matters and execute consents for compromise and closing agreements. The authority does not include the power to endorse or cash warrants. List any specific limitations or deletions to the acts otherwise authorized in the Power of Attorney. Section 5. Retention/Nonrevocation of Prior Power s of Attorney The filing of this Power of Attorney will not revoke earlier Power s of Attorney on file with the Florida Department of Highway Safety and Motor Vehicles even for the same matters covered by this document. If you want to revoke a prior Power of Attorney check this box. You must attach a copy of any Power of Attorney you wish to revoke. The individual signing the Power of Attorney is affirming that he or she is authorized to execute the Power of Attorney For a corporation or any other entity A corporation officer or person having authority to bind the entity must sign* For partnerships All partners must sign unless one partner is authorized to act in the name of the partnership* For a sole proprietorship The owner of the sole proprietorship must sign* Under penalties of perjury I we declare that I we have read the foregoing document and the facts stated in it are true.

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