Limited Power Of Attorney And Tax Information Authorization Form printable pdf download

VERMONT DEPARTMENT OF LABOR

VT Unemployment Account Number

ATTN: Employer Services

P.O. Box 488

Montpelier, VT 05601-0488

Federal Identification Number

Phone: 802-828-4344

Fax: 802-828-4248

Limited Power of Attorney and

Client Number

Tax Information Authorization

(Business, Estate or Trust)

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 NOT selected, please specify the client address where benefit claim related information should be mailed)

Address in Fact: _________________________________

Client Address: _________________________________

(C-101 Forms, Rate ________________________________

(Only Benefit Claim _______________________________

Notices, Statements) ________________________________

Related Information) ______________________________

Telephone No.: ___________________________________

Telephone No.: _________________________________

This Limited Power of Attorney form is effective for the period beginning ________________ and will remain in effect until

(Quarter/Year)

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 __________________________________

, 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)

Limited Power Of Attorney And Tax Information Authorization Form

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