mr-69-v(2008-11)_inc

MR-69-V 2008-11 Page 1 of 2 Ministère du Revenu Power of A ttorney , Authorization to Communicate Information, or Revocation Complete this form 1 if you wish to • authorizethe Ministèredu Revenuto communicateconfidential informa- tiontoadesignatedpersonandallowthepersontoconsultdocuments containingsuchinformation( authorization); • appo int a mand ata ry to rep res ent you with the Minis tèr e du Revenu (power of attorney).Underthepowerofattorney,theMinistèremay disclosetothemandatary(thepersontowhomamandateisgivenbythe mandator)the informationnecessaryfor carryingout themandate andmay allowthemandatarytoconsultdocumentscontainingsuchinformation. Themandatarymayalsorequesttax-relatedchanges; • revoke ormodifyanauthorizationorpowerofattorneythathasalready beensubmittedtotheMinistère( revocation). Th e authorization or power of attorney may relate to one or more laws administeredbytheMinistèreduRevenu( TaxationAct,Actrespectingthe Québec sales tax, Fuel Tax Act, Tobacco Tax Act, Excise Tax Act, Act to facilitate thepaymentofsupport ,etc.). If you are completing this form as the authorized representative ofanother person,youmustprovidethedocumentsattestingthatyouareauthorized toactontheperson’sbehalf.Thisrequirementdoesnotapplyifyouareone ofthepartnersofapartnershiporthe president, vice-president, secretaryor treasurerofacorporation. V alidity period of an authorization or a power of attorney Anauthorizationorapowerofattorneyisvalidfora maximum of three years from the date of the signature. When the three-year period has elapsed, theauthorizationorpowerofattorneymustberenewed. Youmay modify or revoke anauthorizationorapowerofattorneyat anytime. Return this form, duly completed and signed, to one of the following addresses. Photocopies are not accepted. • 3800, ruedeMarly ,Québec(Qué bec)G1X4A5 • ComplexeDesjardins,C.P.3000 ,succursaleDesjardins Montréal(Québec)H5B1A4 1 Identification 1.1 Person who authorizes the communication of information or who grants a power of attorney (mandator) 1.2 Person to whom the Ministèr e is authorized to communicate information or to whom a power of attor ney is granted (mandatary) 1. Thefor mmaybecomple tedbyanind ividual(includinga nindividualinbu siness),acor poration, apartner ship, atrust,e tc. Parts to be completed Nameofbusinessorlastnameandrstnameofindividual Areacode Telephone Extension Address Postalcode Indicate the numbers applicable: Socialinsurancenumber Québecenterprisenumber(NEQ) Identicationnumber T o grant authorization or a power of attorney, complete P arts 1, 2 and 3 of this form. To revoke an authorization or a power of attorney, co mplete section 1.1 and Part 4. T o modify an authorization or a power of attorney, complete Parts 1, 2, 3 and 4. Y ou 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). Nameofbusinessorlastnameandrstnameofindividual Areacode Telephone Extension Address Postalcode Indicate the numbers applicable: Québecenterprisenumber(NEQ) Identicationnumber ASL Solutions Reg'd 5 1 4 4 3 309 5 0 5947 Chabot street, Montreal, QC. H2G2S9 2267169391 2267169391 Continued Navigation pointers Erase E

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