Patriot Software Tax Processing Authorization Form
Taxpayer Information
Company Name:
Doing Business As:
EIN:
Address:
Phone:
Reporting Agent Information
Company Name:
Patriot Software, Inc.
EIN:
Address:
800 Market Avenue N.
Canton, OH 44702
Phone:
52-2374684
(330) 455-9218
(330) 454-5451
Fax:
Tax Information
Enter Tax information for all taxes to be handled by Reporting Agent:
Tax Entity
Type of Tax
ID #
Starting Date of Service
Acts Authorized
Taxpayer grants the above named Reporting Agent Power of Attorney to perform any and all acts that Taxpayer can perform
with respect to the tax matters described above, including the authority to sign any agreements, returns, consents, waivers, and
other documents.
This authority does not include the power to receive refund checks, the power to substitute another representative, or the power
to execute a request for disclosure of tax returns or return information to a third party.
Taxpayer authorizes that the above Agent may receive confidential information, discuss tax matters, and make decisions on our
behalf. This authorization remains in effect until the Taxpayer or Agent notifies the other that this authorization is terminated
or revoked.
Taxpayer authorizes the Agent named above to make tax payments and sign and file tax returns transmitted electronically for
the tax forms indicated above.
EFT Contact Person
Name:
Fax:
Doug Simmons
(330) 454-5451
Phone:
Email:
(330) 455-9218 ext 490
[email protected]
Signature Authorization
Under penalties of perjury, I state that I have examined this form and to the best of my knowledge it is true, correct, and
complete. I understand that this authorization does not absolve me as the taxpayer of the responsibility to ensure that all tax
returns are filed and all taxes are paid on time.
Taxpayer Signature:
Taxpayer’s Printed Name and Title:
Date: