Application Procedures for Approval of Benefit Suspensions for Certain Multiemployer Defined Benefit Pension Plans under § 432(e)(9)

Appendix B
POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE BEFORE THE DEPARTMENT OF THE
TREASURY
Applicant information [include name of plan, address, plan number, employer identification number, name of contact,
title of contact, telephone number, email address, and fax number]:
Applicant hereby appoints the following representative(s) as attorney(s)-in-fact to represent the taxpayer before the Department of
the Treasury and perform acts related to the attached application dated ______________ for suspension of benefits under § 432(e)(9)
of the Internal Revenue Code of 1986, as amended.
Representative information: [include name, address, employer identification number, telephone number, email address,
and fax number]:
Send copies of notices and communications to representative [answer yes or no]
With the exception of the acts described below, I authorize my representative(s) to receive and inspect my confidential tax
information and to perform acts that I can perform with respect to the attached application dated ______________ for suspension
of benefits under § 432(e)(9). For example, my representative(s) shall have the authority to sign any agreements, consents, or similar
documents.
Specific acts not authorized: [If the representative is not authorized to perform any act described above, describe the act that the
representative is not authorized to perform.]
Signature of Applicant and Date
This power of attorney must be signed and dated by an authorized trustee who is a current member of the board of trustees.

Declaration of Representative
Under penalties of perjury, by my signature below I declare that:
• I am not currently suspended or disbarred from practice before the Internal Revenue Service;
• I am authorized to represent the Applicant for the matter(s) specified in this Power of Attorney and Declaration of Representative;
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
d Officer—a bona fide officer of the Applicant.
e Full-Time Employee—a full-time employee of the Applicant.
f Enrolled Actuary— enrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the authority
to practice before the Internal Revenue Service is limited by section 10.3(d) of Circular 230).
g Enrolled Retirement Plan Agent
Required information for Representative [include the appropriate designation of a through g above. In addition, an officer or full-time
employee of the Applicant must include the title or position with the Applicant, and other Representatives must include the licensing
jurisdiction if applicable, and the bar, license, certification, registration, or enrollment number as applicable.]:
Signature of Representative and date:

Bulletin No. 2016 –19

735

May 9, 2016