Home > Legal > Legal > Power of Attorney Template > Vermont Power of Attorney Form > Vermont Limited Power of Attorney and Tax Information Authorization Template

Vermont Limited Power of Attorney and Tax Information Authorization Form


Vermont Limited Power of Attorney and Tax Information Authorization Form
Vermont Limited Power of Attorney and Tax Information Authorization Form
VERMONT DEPARTMENT OF LABOR
ATTN: Employer Services
P.O. Box 488
Montpelier, VT 05601-0488
Phone: 802-828-4344
Limited Power of Attorney and
Tax Information Authorization
(Business, Estate or Trust)
V
T Unemployment Account Number
Federal Identification Number
Client Number
Taxpaper's Legal Business Name: ____________________________________________________________________
Trade Name(s): ___________________________________________________________________________________
hereby appoints ______________________________________ as its agent to perform the following acts on its behalf:
(check all that apply):
Receive, prepare and file new and amended Vermont Employer's Quarterly Wage & Contribution Report forms.
Obtain from and provide to this agency information regarding its returns filed for periods on or after the date below.
Discuss matters as they pertain to the rate assignments and experience rating.
Process all necessary forms/inquiries as they pertain to claims potentially filed against its rating/account.
(If this box is NO
T
selected, please specify the client address where benefit claim related information should be mailed)
Address in Fact: _________________________________
(C-101 Forms, Rate ________________________________
Notices, Statements) ________________________________
Telephone No.: ___________________________________
Client Address: _________________________________
(Only Benefit Claim _______________________________
Related Information) ______________________________
Telephone No.: _________________________________
This Limited Power of Attorney form is effective for the period beginning ________________ and will remain in effect until
this department is otherwise notified.
It applies only to the items which have been selected above as they pertain to the Unemployment Insurance Tax and/or
Benefit related matters for the client.
This limited Power of Attorney revokes all prior Powers of Attorney on file with the Vermont Department of Labor.
________________________________________ ______________________
Person Completing and Signing Power of Attorney Date
________________________________________ ______________________________________
Signature Title of Person Signing Power of Attorney
AFFIRMATION OF WITNESS
I, ______________________________ affirm that _________________________________ appeared to be of sound
mind and free from duress at the time this Limited Power of Attorney was signed, and that (s)he affirmed that (s)he was
aware of the nature of this document and signed it freely and voluntarily.
_________________________________________ ______________________
Signature of Witness (Cannot be same as Notary) Date
FOR USE BY NOTARY
STATE OF_____________________________________
COUNTY OF __________________________________
(Quarter/Year)
, SS.
At _________________________ on the _______ day of __________________________ personally appeared
___________________________________ who acknowledged this Instrument and signed by him/her as his/her free act and
deed, and before me,
________________________________________ . My Commission expires: ____________________________
Signature of Notary Public
C-50 (10/10)
(PLEASE COMPLETE PAGE 2)
Fax: 802-828-4248
Vermont Limited Power of Attorney and Tax Information Authorization Form
Previous

1/2

Next