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  4. Quebec Power of Attorney, Authorization to Communicate Information, or Revocation Form

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MR-69-V
2008-11
Page 1 of 2
Ministère du Revenu
Power of Attorney, Authorization
to Communicate Information, or Revocation
Complete this form
1
if you wish to
• authorizetheMinistèreduRevenutocommunicateconfidentialinforma-
tiontoadesignatedpersonandallowthepersontoconsultdocuments
containingsuchinformation(authorization);
• appointa mandatary torepresent you with the Ministère du Revenu
(power of attorney).Underthepowerofattorney,theMinistèremay
disclosetothemandatary(thepersontowhomamandateisgivenbythe
mandator)theinformationnecessaryforcarryingoutthemandateandmay
allowthemandatarytoconsultdocumentscontainingsuchinformation.
Themandatarymayalsorequesttax-relatedchanges;
• revokeormodifyanauthorizationorpowerofattorneythathasalready
beensubmittedtotheMinistère(revocation).
The authorization orpower ofattorneymay relate to one or more laws
administeredbytheMinistèreduRevenu(
TaxationAct,Actrespectingthe
Québecsalestax,FuelTaxAct,TobaccoTaxAct,ExciseTaxAct,Acttofacilitate
thepaymentofsupport
,etc.).
Ifyouarecompletingthisformastheauthorized representative ofanother
person,youmustprovidethedocumentsattestingthatyouareauthorized
toactontheperson’sbehalf.Thisrequirementdoesnotapplyifyouareone
ofthepartnersofapartnershiporthepresident,vice-president,secretaryor
treasurerofacorporation.
Validity period of an authorization or a power of attorney
Anauthorizationorapowerofattorneyisvalidforamaximum of three
years fromthedateofthesignature.Whenthethree-yearperiodhaselapsed,
theauthorizationorpowerofattorneymustberenewed.
You maymodify or revoke anauthorizationorapowerofattorneyat
anytime.
Returnthisform,dulycompletedandsigned,tooneofthefollowingaddresses.
Photocopies are not accepted.
• 3800,ruedeMarly,Québec(Québec)G1X4A5
• ComplexeDesjardins,C.P.3000,succursaleDesjardins
Montréal(Québec)H5B1A4
1 Identification (please print)
1.1 Person who authorizes the communication of information or who grants a power of attorney (mandator)
1.2 Person to whom the Ministère is authorized to communicate information or
to whom a power of attorney is granted (mandatary)
1. Theformmaybecompletedbyanindividual(includinganindividualinbusiness),acorporation,apartnership,atrust,etc.
(continuedonnextpage)
Parts to be completed
Nameofbusinessorlastnameandrstnameofindividual AreacodeTelephone Extension
Address Postalcode
Indicate the numbers applicable:
Socialinsurancenumber Québecenterprisenumber(NEQ) Identicationnumber
To grant authorization or a power of attorney, complete Parts 1, 2 and 3 of this form.
To revoke an authorization or a power of attorney, complete section 1.1 and Part 4.
To modify an authorization or a power of attorney, complete Parts 1, 2, 3 and 4. You must first revoke the existing authorization
or power of attorney (section 1.1 and Part 4), and then grant another authorization or power of attorney (section 1.2 and Parts 2 and 3).
Nameofbusinessorlastnameandrstnameofindividual AreacodeTelephone Extension
Address Postalcode
Indicate the numbers applicable:
Québecenterprisenumber(NEQ) Identicationnumber
Quebec Power of Attorney, Authorization to Communicate Information, or Revocation Form
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