Form C-50 - Power Of Attorney - 2016 printable pdf download

Form C-50 - Power Of Attorney - 2016

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)

Taxpayer's Legal Business Name: ____________________________________________________________________

Trade Name(s): ___________________________________________________________________________________

hereby appoints ______________________________________ as its agent to perform the following acts on its behalf:

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.

(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.

Address in Fact: _________________________________

(C-101 Forms, Rate ________________________________

Notices, Statements) ________________________________

Telephone No.: ___________________________________

Please specify the client address where benefit claim related information should be mailed.

Client Address: _________________________________

(Only Benefit Claim _______________________________

Related Information) ______________________________

Telephone No.: _________________________________

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.

________________________________________

Date

Person Completing and Signing Power of Attorney

________________________________________

______________________________________

Signature

Title of Person Signing Power of Attorney

(PLEASE COMPLETE PAGE 2)

C-50 (04/16)

Form C-50 - Power Of Attorney - 2016