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POA 1 Indiana Department of Revenue State Form 49357 (R4 / 4-13) POWER OF ATTORNEY 1. Taxpayer Information DBA Name(s) (if applicable) Taxpayer(s) Name(s) Address New Address? City State Zip Code
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Taxpayer Address Mailing Address Telephone Number 4. Signature and Date of Acceptance of a Confidentiality Agreement by the individual Representative in the form attached to this form. Date Signatures Hereby agree to this Privacy Policy, without material change, modification or other omission for any reason.

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