This declaration is valid until .

If no expiration date is given, this declaration will

expire one year after the date that it is signed.
Expiration Date
The taxpayer identified above authorizes the representative identified above to represent the tax-
payer before the Department of Taxation. This authorization includes the authority to view and receive copies of returns,
reports or other documents filed by the taxpayer or prepared by the Department of Taxation concerning the business, property
or transactions of the taxpayer, request alternative methods of taxation, present evidence or legal arguments to any employee
of the Department of Taxation, raise objections to audit findings or assessments, file petitions or applications and waive
statutes of limitation. This authorization does not authorize the tax representative to sign any form or declaration where the
Ohio Revised Code specifically requires that the form or declaration be signed by the taxpayer. The taxpayer understands
that the acts of the authorized representative may increase or decrease the taxpayers tax liabilities and legal
rights. The taxpayer must indicate all restrictions, if any, to this authorization in the space below.
I certify, under penalties of perjury, that I am the taxpayer or that I am a corporate officer, LLC member, general partner,
guardian, tax manager or similar employee authorized to act on tax matters, executor, receiver, administrator or trustee on
behalf of the taxpayer and that I have the authority to execute this form on behalf of the taxpayer. If this form is not properly
completed, this Declaration of Tax Representative will not be processed.
Signature Date
Name (print) Title
Telephone number Fax number
TBOR 1
Rev. 2/04
Declaration of Tax Representative
Representative Information
Representatives name and firm
Address
City State ZIP code
Telephone number Fax number
E-mail address
Authorized Signature
Restrictions to this Declaration
The following restrictions are placed on this Declaration of Tax Representative:
Send this declaration to: Ohio Department of Taxation, Office of Chief Counsel TBOR 1, P.O. Box 530. Columbus, OH 43216-
0530, or fax to (614) 466-7979. (Use same address to revoke declaration.)
Taxpayers name
Business name
Address
City State ZIP code
FEIN or social security number
(Only use social security number if requesting individual income tax representative or if business does not have a FEIN.)
P.O. Box 530 Columbus, OH 43216-0530
TB REFUND LTD., IDA BUSINESS & TECHNOLOGY PARK, RING ROAD
KILKENNY, IRELAND
TAXBACK INC.,
333 NORTH MICHIGAN AVENUE, SUITE 2415,
CHICAGO IL 60601-0000
(888) 203-8900 (312) 781-2707
tafdocuments@taxback.com
INSTRUCCIONES DE DOCUMENTOS
Para recibir tu reembolso de impuestos de los EE.UU. necesitamos que:
Firmes los tres formularios tributarios del IRS (Formularios 2848, 8821 y 8822) y
|uego erv|ar|os por correo e|eclrr|co jurlo cor lus docurerlos de pago, a|gura |derl|lcac|r y rueslro Acuerdo
de Cliente.
Por lavor |rpr|re eslos 3 lorru|ar|os y rueslro Acuerdo de C||erle y lrra de |a s|gu|erle rarera:
Formulario 2848 dos pginas:
Pgina 1: Por favor pon tus iniciales (las primeras letras de tu primer nombre y de tu apellido)
Donde esta el lapicero negro.
Pg|ra 2: Por lavor lrra y lecra e| Forru|ar|o dorde eslr |os |ap|ceros regros.
Forru|ar|os 8821 y 8822 - por lavor so|o lrra y lecra |os lorru|ar|os.
Forru|ar|o de Acuerdo de| C||erle - por lavor lrra y lecra.
ID Envanos una fotocopia de tu tarjeta de social security. Si no tiene una, por favor envanos copia de tu visa
de |os EE.uu. o |a roja cor lolo de lu pasaporle.
Tus docurerlos de pago - |a oo|ela de pago lra| o |a w2 de cada erp|eador.
Tus detalles de contacto si tienes un nmero de celular o correo electrnico nuevo, por favor brndanos
los detalles. Necesitamos estos para poder enviarte tu dinero.
La forma ms rpida de recibir tu reembolso es: Escanear estos documentos y enviarlos por correo electrnico a
tafdocuments@taxback.com.
El IRS requiere que estos documentos sean escaneados de la siguiente manera:
1. Por lavor, corlgura e| lararo de| escareo a| eslrdar Arer|caro:
1. A|lo: 11 pu|gadas (2Z9rr);
2. Arcro: 8.5 pu|gadas (21rr).
2. Corlgura |a ca||dad de lolo a 8|arco y Negro;
3. Corlgura |a reso|uc|r a 300 dp| (dols per |rcr);
1. Por lavor, graoa e| arcr|vo er lorralo P0F o JPE0;
5. E| lararo de |os arcr|vos escareados ro deoe exceder 2V8.
3| eslas ler|erdo d|lcu|lades cor esle escareado por lavor coruricale cor rosolros er www.taxback.com/chat
o uo|ca a |a olc|ra| |oca| er www.taxback.com/contactus.asp
taxback.com
Ocina PrincipaI en
EE.UU.
333N. V|cr|gar Ave.
3u|le 2115
Cr|cago, lL 001
u3A
P: 001 888 203 8900
F: 001 312 8Z3 1202
E: |rlo_laxoac|.cor
w: WWW.laxoac|.cor
Direccin en Europa:
l0A 8us|ress &
Tecrro|ogy Par|
R|rg Road, K|||erry
Ireland
P: 00353 1 88Z 1999
F: 00353 1 Z0 93
Visita WWW.laxoac|.cor para mayores detalles acerca de nuestros servicios.
V|erlras rs |rlorrac|r puedas or|rdar, rs rp|do rec|o|rs lu reeroo|so
US/ EEUU
TAX REFUND/ REEMBOLSO DE IMPUESTOS
VISA INFORMATION / INFORMACIN DE VISADO:
P|ease X lre correcl opl|or / Por favor marque con X la opcin correcta: v|sa Type / T|po de v|sa:
Prograr lype / Tipo de Programa:
wor| ard Trave| Intern 0lrer/ 0lro J1 F1 l18 l28 Q L E P O 0lrer / Otro:
0ale ol arr|va| |r lre u3A / Fecra de ||egada a EE.uu.: DAY MONTH YEAR 0ale ol deparlure lror lre u3A / Fecra de sa||da de EE.uu.: DAY MONTH YEAR
lave you app||ed lor lr|s relurd oelore/ Has solicitado este reembolso antes? Yes No
wral Was lre cosl ol your prograrre lo lre u3 / Cul fue el costo de tu programa a los EE.UU.? $
wral Was lre cosl ol your l|grl lo lre u3 / Cul fue el costo de tu boleto areo a EE.UU.? $
Personas con visa que paguen por gastos de vivienda en sus paises de origen mientras esten en su programa de EE.UU. podran recibir reembolsos
de impuestos legalmente mayores.
P|ease l|c| Wr|cr ||v|rg experses you pa|d lor |r your rore courlry, Wr||e you Were or your u3 prograr / Por lavor se|ecc|ora qu gaslos de v|v|erda pagasle er lu pais de or|ger, r|erlras esluv|sle er lu prograra de EE.uu.:
lrsurarce (red|ca|, rore, ver|c|e, elc) / Voo||e prore cosls / C|uo reroersr|p (gyr, sporls, soc|a|, elc) /
3eguro (rd|co, de v|v|erda, ver|cu|ar, elc.): 0aslos de le|eloria ce|u|ar: Veroresia de c|uo (g|rras|o, deporl|vo, soc|a|, elc):
lous|rg cosls (rerl, rorlgage, ooard, elc) / Trarsporlal|or (car, roloro||e, o|cyc|e, elc) / 0lrer /
0aslos de v|v|erda (a|qu||er, r|poleca, pers|r, elc): Transporte (automvil, motocicleta, bicicleta, etc): Otros:
2
US/ EEUU
TAX REFUND/ REEMBOLSO DE IMPUESTOS
tafdocuments@taxback.com
APPLICATION FORM / FORMUlARIO DE REgISTRO
EMPLOYMENT INFORMATION / INFORMACIN DE EMPLEO
1
st
Corpary Nare / Nombre de 1
er
Empleador: F|ra| Wor| dale / ltimo da de trabajo: DAY MONTH YEAR
C|ly / Ciudad: 3lale / Estado: Tel:
0o you rave your w2 Forr?/ T|eres lu lorru|ar|o w2? Yes No ll ro, Wou|d you |||e us lo gel a rep|acererl lor you?/ Si contestaste No, te
gustara que consigamos un duplicado por ti? Yes No
2
nd
Corpary Nare / Nombre de 2do Empleador: F|ra| Wor| dale / ltimo da de trabajo: DAY MONTH YEAR
C|ly / Ciudad: 3lale / Estado: Tel:
0o you rave your w2 Forr?/ T|eres lu lorru|ar|o w2? Yes No ll ro, Wou|d you |||e us lo gel a rep|acererl lor you?/
Si contestaste No, te gustara que consigamos
un duplicado por ti? Yes No
CONTACT INFORMATION / INFORMACIN DE CONTACTO:
P LEASE PRINT IN BLOCK CAPITALS in ENGLISH / POR fAvOR ESCRIBE EN LEtra ImPrENta
Vr/Sr: Vrs/Sra: Vs/Srta.:
F|rsl Nare / Primer Nombre:
3urrare / Ape|||dos: V|dd|e lr|l|a| / lr|c|a| de Segundo Nombre:
0ale ol 8|rlr / Fecra de Nac|r|erlo: DAY MONTH YEAR Tel:
Era||: Voo||e / Celular:
lore Courlry / Pas de origen:
wr|cr le|| a lr|erd agerl recorrerded you / Qu agente tell a friend te recomend? ingresa nombre del agente
Posla| address / Direccin de Domicilio:
Llena y frma estos formularios. Adjunta tu formulario de poder frmado, Tus W2,
boletas de pago acumulativos y una copia de tu tarjeta Social Security Escanalos y
envalos todos por correo electrnico a tafdocuments@taxback.com
1
Firma los
formularios
1 2
Recibe tu
reembolso
3
Envalo con
tu info de
impuestos
Podras tener derecho a un reembolso legalmente mayor si tuviste un trabajo a tiempo completo/parcial en tu pas de origen antes y
despus de tu programa de EE.UU., y/o si mantuviste a alguien en tu pas de origen mientras estuviste en los EE.UU.
1. 0|d you rave a joo |r your rore courlry? / Tuviste un empleo en tu pas de origen? Yes No
2. 0o you |rlerd lo relurr lo lral joo Wrer you |eave lre u3? / Piensas retornar a ese empleo cuando dejes los EE.UU.? Yes No
3. 0o you rave a perrarerl address |r your rore courlry? / Tienes una direccin domiciliar permanente en tu pas de origen? Yes No
1. 0o you |rlerd lo relurr lo lr|s address Wrer you |eave lre u3? / Piensas retornar a esta direccin cuando dejes los EE.UU.? Yes No
5. 0|d you pay rorey loWards a rousero|d |r your rore courlry Wr||e |r lre u3?/
Pagasle d|rero rac|a a|gura v|v|erda er lu pais de or|ger r|erlras esluv|sle er |os EE.uu.? Yes No
. Are you erl|l|ed lo vole |r your rore courlry? / T|eres derecro de volar er lu pais de or|ger? Yes No
Z. 0o you rave a oar| accourl |r your rore courlry? / Tienes una cuenta bancaria en tu pais de orgen? Yes No
8. 0|d you rece|ve ra|| lo your rore address Wr||e |r lre u3?/
Recibiste correspondencia en tu direccin domiciliar mientras estuviste en los EE.UU.? Yes No
3
f you had more than two employers please include information on a separate page. / Si tuviste ms de dos empleadores por favor incluye la informacin en una hoja separada
V|erlras rs |rlorrac|r puedas or|rdar, rs rp|do rec|o|rs lu reeroo|so
0ocurerl relr|eva| lee app||es/ Tar|la de Recuperac|r de 0ocurerlo ap||car
taxback.com
Ocina PrincipaI en
EE.UU.
333N. V|cr|gar Ave.
3u|le 2115
Cr|cago, lL 001
u3A
P: 001 888 203 8900
F: 001 312 8Z3 1202
E: |rlo_laxoac|.cor
w: WWW.laxoac|.cor
Direccin en Europa:
l0A 8us|ress &
Tecrro|ogy Par|
R|rg Road, K|||erry
Ireland
P: 00353 1 88Z 1999
F: 00353 1 Z0 93
Nare |r pr|rl / Nombre en imprenta: 0ale / Fecra:
3|gralure / Firma: Social Security Number / Nurero de 3oc|a| 3ecur|ly:

CUSTOMER AgREEMENT / ACUERDO DEl ClIENTE
Visita WWW.laxoac|.cor para mayores detalles acerca de nuestros servicios.
tafdocuments@taxback.com
l corlrr lral / Yo corlrro que
1. l urderslard lral laxoac|.cor |s a lrad|rg rare lor lre serv|ces ol Taxoac| lrc., Cr|cago, u3A, ard rereoy corlracl W|lr
Taxoac| lrc. lo carry oul lre serv|ces descr|oed rereW|lr. / Erl|erdo que laxoac|.cor es e| rorore corerc|a| para |os
serv|c|os de Taxoac| lrc., Cr|cago, u3A,y por |o larlo corlralo a Taxoac| lrc. Para ||evar a caoo |os serv|c|os
descritos adjunto.
2. l urderslard lral Taxoac| lrc W||| ul|||se |ls parerl corpary Taxoac| Lld ard |ls suos|d|ary ard all||ale corpar|es lo galrer
|rlorral|or regard|rg lre serv|ces Wrere recessary ard lral lre corlracl rera|rs W|lr Taxoac| lrc lor lre dural|or ol lre
serv|ce. / Erl|erdo que Taxoac| lrc ul|||zar a su erpresa radre Taxoac| Lld y sus suos|d|ar|as y corparias al||adas
para reur|r |rlorrac|r relererle a |os serv|c|os, dorde sea recesar|o y que e| corlralo perrarece cor Taxoac| lrc por
la duracin del servicio.
3. l rave s|gred lre recessary poWer ol allorreys lo aulror|ze Taxoac|. lrc, ard / or |ls suos|d|ary urderla||rgs lrad|rg
as laxoac|.cor ard relerred lo rerealler as lre Agerl, lo prepare lr|s lax relurr ard represerl re oelore lre u3
Tax Aulror|l|es (lR3 ard 3lale Tax Aulror|l|es). / le lrrado |os poderes recesar|os para aulor|zar a Taxoac|. lrc, y / o sus
suos|d|ar|as corerc|a||zardo coro laxoac|.cor y er ade|arle reler|do coro e| Agerle, a preparar esla so||c|lud de
reeroo|so de |rpueslos y represerlarre arle |as Aulor|dades Tr|oular|as de |os EE.uu. (lR3 ard 3lale Tax Aulror|l|es).
1. l aulror|ze lre Agerl lo rece|ve a|| corresporderce lror lre u3 Tax Aulror|l|es or ry oera|l. / Aulor|zo o Aulor|zo a|
Agerle a rec|o|r loda corresporderc|a de |as Aulor|dades Tr|oular|as de |os EE.uu. er rorore rio.
5. l Warl lo ava|| ol lre oller lo 'pay ro lee up-lrorl Wrer l s|gr up lor lre serv|ce. lr order lo ava|| ol lr|s opl|or, l urderslard lral
lre lee W||| reed lo oe pa|d oy re Wrer lre relurd ras oeer |ssued oy lre u3 Tax Aulror|l|es. / 0eseo racer opc|r de |a olerla
's|r pagos de arleraro cuardo aceple e| serv|c|o. Para poder se|ecc|orar esla opc|r, erl|erdo que e| cooro de |a lar|la lerdr
que ser pagada por r| cuardo e| reeroo|so raya s|do er|l|do por |as Aulor|dades Tr|oular|as de EE.uu.
. l aulror|ze lre Agerl lo rece|ve ry relurd creque(s) lror lre Tax Aulror|l|es. / Aulor|zo a| Agerle para rec|o|r r| creque(s)
de reeroo|so de |as Aulor|dades Tr|oular|as.
Z. l lurlrer aulror|ze lre Agerl lo erdorse lre creques, deducl lre recessary lee ard lo serd re lre rera|r|rg arourl. / As|r|sro aulor|zo a|
Agerle erdosar |os creques, descorlar |a lar|la recesar|a y erv|arre e| rorlo rerarerle.
8. l urderslard lral orce ry relurd |s processed, l W||| oe corlacled oy lre Agerl W|lr regard lo payrerl opl|ors lor rece|v|rg ry relurd ard W||| oe ao|e
lo prov|de ry oar| dela||s. / Erl|erdo que ura vez que se raya procesado r| reeroo|so, ser corlaclado por ur Asesor cor relererc|a a |as opc|ores
de pago para recibir mi reembolso y podr brindar mis detalles bancarios.
9. 3rou|d lre Agerl croose lor ary reasor rol lo erdorse lre creque, l urderslard ard agree lral l W||| pay lre lee due ard W||| casr lre lax ollce relurd
creque ryse|l. / Er caso que e| Agerle e||ja por a|gura razr ro erdosar e| creque, erl|erdo y esloy de acuerdo de que pagar |a lar|la deo|da y
coorar e| creque de reeroo|so de |rpueslos por r| cuerla.
10. 3rou|d l rece|ve lre relurd d|recl|y lror ary olrer source olrer lrar lre Agerl, l urderslard ard agree lral l W||| pay lre lee due lo lre Agerl lor
lre Wor| corp|eled. / Er caso rec|oa r| reeroo|so d|reclarerle de olra luerle que ro sea e| Agerle, erl|erdo y esloy de acuerdo que pagar |a
lar|la correspord|erle a| Agerle por e| lraoajo rea||zado.
11. 3rou|d l oWe |rcore lax lor olrer lax years, ard lre u3 Tax Aulror|l|es deducl lr|s oWed rorey lror lre relurd due lor olrer lax year (s), l urderslard
ard agree lral l reed lo pay lre Agerl process|rg lee lor eacr lax year lor Wr|cr a lax relurr Was processed. / En caso de estar debiendo impuestos
por olros aros lsca|es, y |as Aulor|dades Tr|oular|as de |os EE.uu. descuerler esla deuda perd|erle de olros aros lsca|es, erl|erdo y esloy de
acuerdo que reces|lar pagar a| Agerle |a lar|la de procesar|erlo por cada aro lsca| que se raya so||c|lado ur reeroo|so.
12. l urderslard lral lre u3 Tax Aulror|l|es W||| ra|e lre lra| dec|s|or or lre va|ue ol ary relurd due. l urderslard lral lre Agerl W||| prov|de lre oesl esl|ral|or
poss|o|e oased or currerl lax |aW ard |rlorral|or g|ver, roWever lr|s |s esl|ral|or or|y, rol a guararlee. / Erl|erdo que |as Aulor|dades Tr|oular|as de |os
EE.uu. lorarr |a dec|s|r lra| soore e| va|or de cua|qu|er reeroo|so que se deoa. Erl|erdo que e| Agerle or|rdar e| rejor c|cu|o Esl|rado pos|o|e
basndose en las actuales leyes tributarias y la informacin proporcionada, sin embargo este clculo es solo un estimado, no una garanta.
13. l agree lo ard accepl lre lerrs ard cord|l|ors ol serv|ce as Wr|ller or||re al WWW.laxoac|.cor ard lo ary crarges |r lre lerrs ard cord|l|ors Wr|cr
Taxoac| lrc ray allecl lror l|re lo l|re, ard lo lre lees ol lre agerl Wr|cr represerls lre serv|ces l rave requesled ard Wr|cr are prov|ded oy Taxoac| lrc
ard/or |ls all||ale corpar|es. / Esloy de Acuerdo cor |os lrr|ros y |as cord|c|ores de serv|c|os, la| y coro descr|los er |irea er WWW.laxoac|.cor, y coro
podriar ser rod|lcados er a|gur rorerlo, y cor |as lar|las de| Agerle que represerlar |os serv|c|os de| cua| re aceplado de| Agerle.
11. l urderslard lral |rlorral|or co||ecled |r Wr|l|rg ard/or veroa||y lor u3 lax relurr l||rg serv|ces car ard ray oe used lor |rlerra| aud|l|rg purposes oy
laxoac|.cor ard prov|ded lo lre u3 Tax Aulror|l|es (lR3 ard 3lale Tax Aulror|l|es) lor exlerra| aud|l|rg purposes, suojecl lo re|evarl dala prolecl|or |eg|s|al|or.
/ Erl|erdo que |a |rlorrac|r reco|eclada por escr|lo y / o veroa|rerle para |os serv|c|os de preserlar ura so||c|lud de reeroo|so de |rpueslos podria ser
ul|||zada para props|los de aud|loria |rlerra de laxoac|.cor y proporc|orada a |as Aulor|dades Tr|oular|as de |os EE.uu. (lR3 ard 3lale Tax Aulror|l|es)
para props|los de aud|lor|a exlerra, sujelo a |a |eg|s|ac|r correspord|erle a |a prolecc|r de dalos.
15. l corlrr lral l rave g|ver lre Agerl a|| |rlorral|or reeded ard ava||ao|e lo re. / Corlrro que |e re or|rdado a| Agerle loda |a
|rlorrac|r recesar|a y que raya eslado a r| d|spos|c|r.
1. l corr|l lo updal|rg lre Agerl ol ary crarge |r ry corlacl dela||s. / Ve corprorelo a aclua||zar cor e| Agerle, cua|qu|er
detalle de contacto mo que cambie.
V|erlras rs |rlorrac|r puedas or|rdar, rs rp|do rec|o|rs lu reeroo|so
taxback.com
Ocina PrincipaI en
EE.UU.
333N. V|cr|gar Ave.
3u|le 2115
Cr|cago, lL 001
u3A
P: 001 888 203 8900
F: 001 312 8Z3 1202
E: |rlo_laxoac|.cor
w: WWW.laxoac|.cor
Direccin en Europa:
l0A 8us|ress &
Tecrro|ogy Par|
R|rg Road, K|||erry
Ireland
P: 00353 1 88Z 1999
F: 00353 1 Z0 93
US/ EEUU
TAX REFUND/ REEMBOLSO DE IMPUESTOS
Form

2848

OMB No. 1545-0150

Power of Attorney
and Declaration of Representative

(Rev. June 2008)
Department of the Treasury
Internal Revenue Service

Power of Attorney

Taxpayer information. Taxpayer(s) must sign and date this form on page 2, line 9.

1

Employer identification
number

Social security number(s)

Taxpayer name(s) and address

Plan number (if applicable)

Daytime telephone number

hereby appoint(s) the following representative(s) as attorney(s)-in-fact:

Representative(s) must sign and date this form on page 2, Part II.

2

CAF No.

Name and address

Telephone No.

Fax No.
Telephone No.

Check if new: Address

Name and address

Telephone No.

Fax No.
Telephone No.

Check if new: Address

Name and address

Telephone No.

Fax No.
Telephone No.

Check if new: Address

to represent the taxpayer(s) before the Internal Revenue Service for the following tax matters:

Tax matters

3

Year(s) or Period(s)
(see the instructions for line 3)

Tax Form Number
(1040, 941, 720, etc.)

Type of Tax (Income, Employment, Excise, etc.)
or Civil Penalty (see the instructions for line 3)

Specific use not recorded on Centralized Authorization File (CAF). If the power of attorney is for a specific use not recorded on CAF,
check this box. See the instructions for Line 4. Specific Uses Not Recorded on CAF

4

Acts authorized. The representatives are authorized to receive and inspect confidential tax information and to perform any and all acts that
I (we) can perform with respect to the tax matters described on Iine 3, for example, the authority to sign any agreements, consents, or other
documents. The authority does not include the power to receive refund checks (see line 6 below), the power to substitute another representative
or add additional representatives, the power to sign certain returns, or the power to execute a request for disclosure of tax returns or return
information to a third party. See the line 5 instructions for more information.

5

List any specific additions or deletions to the acts otherwise authorized in this power of attorney:

6

Receipt of refund checks. If you want to authorize a representative named on Iine 2 to receive, BUT NOT TO ENDORSE OR CASH, refund
checks, initial here and list the name of that representative below.

Name of representative to receive refund check(s)


Cat. No. 11980J

Form 2848 (Rev. 6-2008)

Part I


Name

Telephone

Function

Date

For IRS Use Only

/

/

Received by:

For Privacy Act and Paperwork Reduction Act Notice, see page 4 of the instructions.

Type or print.

See the separate instructions.

( )

CAF No.

CAF No.

Caution: Form 2848 will not be honored for any purpose other than representation before the IRS.

Fax No.

Fax No.

Fax No.

Exceptions. An unenrolled return preparer cannot sign any document for a taxpayer and may only represent taxpayers in limited situations.
See Unenrolled Return Preparer on page 1 of the instructions. An enrolled actuary may only represent taxpayers to the extent provided in
section 10.3(d) of Treasury Department Circular No. 230 (Circular 230). An enrolled retirement plan administrator may only represent taxpayers
to the extent provided in section 10.3(e) of Circular 230. See the line 5 instructions for restrictions on tax matters partners. In most cases,
the student practitioners (levels k and l) authority is limited (for example, they may only practice under the supervision of another practitioner).



c/o TB Refund Ltd., IDA Business & Technology Park,
Ring Road, Kilkenny, Ireland
AK Tax Services Inc., 1835 N. Milwaukee,
Chicago, IL 60647
773 252 808
Taxback Inc., 333 North Michigan Ave., Suite 2415
Chicago, IL 60601
888 203 8900
312 873 4202
Individual Income Tax 1040, 1040NR 201, 20, 200, 200
FICA Tax 843, 8316 201, 20, 200, 200
This Power of Attorney is being
filed pursuant to Regulations 1.6012-1(a)(5), which requires a Power of Attorney to be attached to the return
if a return is signed by an agent, by reason of continuous absence from the United States.
Page 2

Form 2848 (Rev. 6-2008)

7

Notices and communications. Original notices and other written communications will be sent to you and a copy to the first
representative listed on line 2.

If you also want the second representative listed to receive a copy of notices and communications, check this box


b

If you do not want any notices or communications sent to your representative(s), check this box


8

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 Internal Revenue Service for the same tax matters and years or periods covered by this document. If you do not
want to revoke a prior power of attorney, check here


YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.

Signature of taxpayer(s). If a tax matter concerns a joint return, both husband and wife must sign if joint representation is requested,
otherwise, see the instructions. If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, or
trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.

9

IF NOT SIGNED AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.

Title (if applicable)

Date

Signature

Print Name

Title (if applicable)

Date

Signature

Print Name

Declaration of Representative

Under penalties of perjury, I declare that:

I am not currently under suspension or disbarment from practice before the Internal Revenue Service;

I am aware of regulations contained in Circular 230 (31 CFR, Part 10), as amended, concerning the practice of attorneys, certified public
accountants, enrolled agents, enrolled actuaries, and others;
I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there; and

I am one of the following:
Attorneya member in good standing of the bar of the highest court of the jurisdiction shown below.

a
Certified Public Accountantduly qualified to practice as a certified public accountant in the jurisdiction shown below.

b

Enrolled Agentenrolled as an agent under the requirements of Circular 230.

c

Officera bona fide officer of the taxpayers organization.

d

Full-Time Employeea full-time employee of the taxpayer.

e

Family Membera member of the taxpayers immediate family (for example, spouse, parent, child, brother, or sister).

f

Enrolled Actuaryenrolled 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

Unenrolled Return Preparerthe authority to practice before the Internal Revenue Service is limited by Circular 230, section
10.7(c)(1)(viii). You must have prepared the return in question and the return must be under examination by the IRS. See Unenrolled
Return Preparer on page 1 of the instructions.

h

IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL
BE RETURNED. See the Part II instructions.

Jurisdiction (state) or
identification

DesignationInsert
above letter (ar)

Date

Signature

Part II

a

Form 2848 (Rev. 6-2008)

Caution: Students with a special order to represent taxpayers in qualified Low Income Taxpayer Clinics or the Student Tax Clinic Program (levels
k and l), see the instructions for Part II.

Print name of taxpayer from line 1 if other than individual

PIN Number

PIN Number

Enrolled Retirement Plan Agentenrolled as a retirement plan agent under the requirements of Circular 230 (the authority to practice
before the Internal Revenue Service is limited by section 10.3(e)).

r

Student Attorneystudent who receives permission to practice before the IRS by virtue of their status as a law student under section
10.7(d) of Circular 230.

k

Student CPAstudent who receives permission to practice before the IRS by virtue of their status as a CPA student under section
10.7(d) of Circular 230.

l

Form 8821
OMB No. 1545-1165

Tax Information Authorization
(Rev. August 2008)
Department of the Treasury
Internal Revenue Service

Employer identification number Social security number(s)
3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for
the tax matters listed on this line. Do not use Form 8821 to request copies of tax returns.

(a)
Type of Tax
(Income, Employment, Excise, etc.)
or Civil Penalty

(b)
Tax Form Number
(1040, 941, 720, etc.)

(c)
Year(s) or Period(s)
(see the instructions for line 3)

Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific
use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6


4

Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):

5

a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing
basis, check this box


b If you do not want any copies of notices or communications sent to your appointee, check this box


Retention/revocation of tax information authorizations. This tax information authorization automatically revokes all
prior authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do
not want to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain
in effect and check this box

6

7

Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign. If signed by a
corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify
that I have the authority to execute this form with respect to the tax matters/periods on line 3 above.

Do not use this form to request a copy or transcript of your tax return.
Instead, use Form 4506 or Form 4506-T.

Title (if applicable)
Date Signature
Print Name
Form 8821 (Rev. 8-2008) Cat. No. 11596P

For IRS Use Only

Telephone
Function
Date

/

/

Name
( )

Received by:

(d)
Specific Tax Matters (see instr.)

For Privacy Act and Paperwork Reduction Act Notice, see page 4.

Title (if applicable)
Date Signature
Print Name
To revoke this tax information authorization, see the instructions on page 4.

Taxpayer information. Taxpayer(s) must sign and date this form on line 7.

1

Taxpayer name(s) and address (type or print)

Plan number (if applicable)

Daytime telephone number

Appointee. If you wish to name more than one appointee, attach a list to this form.

2

CAF No.

Name and address

Telephone No.
Fax No.
Telephone No.

Check if new: Address

( )

PIN number for electronic signature
Fax No.

IF NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.

Do not sign this form unless all applicable lines have been completed.

DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

PIN number for electronic signature
Taxback Inc., 333 North Michigan Ave., Suite 2415
Chicago, IL 60601
888 203 8900
312 873 4202

Individual Income Tax 1040, 1040NR 201, 20

Form 8822
(Rev. January 2011)
Department of the Treasury
Internal Revenue Service
Change of Address
a

Please type or print.

a

See instructions on back.
a

Do not attach this form to your return.
OMB No. 1545-1163
Before you begin: If you are changing both your home and business address, use a separate Form 8822 to report each change.
Part I Complete This Part To Change Your Home Mailing Address
Check all boxes this change affects:
1 Individual income tax returns (Forms 1040, 1040A, 1040EZ, 1040NR, etc.)
a
If your last return was a joint return and you are now establishing a residence separate
from the spouse with whom you filed that return, check here . . . . . . . .
a
2 Gift, estate, or generation-skipping transfer tax returns (Forms 706, 709, etc.)
a
For Forms 706 and 706-NA, enter the decedents name and social security number below.
a
Decedents name
a
Social security number
3a Your name (first name, initial, and last name) 3b Your social security number
4a Spouses name (first name, initial, and last name) 4b Spouses social security number
5a Your prior name. See instructions.
5b Spouses prior name. See instructions.
6a Old address (no., street, apt no., city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.
6b Spouses old address, if different from line 6a (no., street, apt no., city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.
7 New address (no., street, apt no., city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.
Part II Complete This Part To Change Your Business Mailing Address or Business Location
Check all boxes this change affects:
8 Employment, excise, income, and other business returns (Forms 720, 940, 940-EZ, 941, 990, 1041, 1065, 1120, etc.)
9 Employee plan returns (Forms 5500, 5500-EZ, etc.)
10 Business location
11a Business name 11 b Employer identification number
12 Old mailing address (no., street, room or suite no., city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.
13 New mailing address (no., street, room or suite no., city or town, state, and ZIP code). If a P.O. box or foreign address, see instructions.
14 New business location, if different from mailing address (no., street, room or suite no., city or town, state, and ZIP code). If a foreign address, see instructions.
Part III Signature
Daytime telephone number of person to contact (optional) a
Sign
Here
F
Your signature Date
F
If Part II completed, signature of owner, officer, or representative Date
F
If joint return, spouses signature Date
F
Title
For Privacy Act and Paperwork Reduction Act Notice, see back of form. Cat. No. 12081V Form 8822 (Rev. 1-2011)

TB RE F UND LTD., IDA BUSINESS & TE CHNOLOGY PARK, RING ROAD, KILK ENNY, IRELAND
POWER OF ATTORNEY
tafdocuments@taxback.com
I, FUll NAME , 0ale ol 8|rlr: MONTH DAY YEAR
SSN (last 4 digits)

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Taxback Inc.
333 N. Michigan Avenue
Suite 2415
Chicago IL 60601
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relurd crec|s |ssued |r ry rare al lre address slaled aoove.
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lre dale lrese rallers are corp|eled.
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to my representative.
(a)
(b)
Signed: Date:
MONTH DAY YEAR
Visita WWW.laxoac|.cor para mayores detalles acerca de nuestros servicios.
V|erlras rs |rlorrac|r puedas or|rdar, rs rp|do rec|o|rs lu reeroo|so
taxback.com
Ocina PrincipaI en
EE.UU.
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3u|le 2115
Cr|cago, lL 001
u3A
P: 001 888 203 8900
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E: |rlo_laxoac|.cor
w: WWW.laxoac|.cor
Direccin en Europa:
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Tecrro|ogy Par|
R|rg Road, K|||erry
Ireland
P: 00353 1 88Z 1999
F: 00353 1 Z0 93
US/ EEUU
TAX REFUND/ REEMBOLSO DE IMPUESTOS