Form Pa-1 - Special Power Of Attorney (Individual) printable pdf download

Form Pa-1 - Special Power Of Attorney (Individual)

Vermont Department of Taxes

133 State Street

Montpelier, VT 05633-1401

Special Power of Attorney

(Individual)

Name

Social Security Number

Name of Spouse / CU Partner (complete only if power of attorney applicable to joint return)

Social Security Number of Spouse/CU Partner

Name of Agent

Telephone Number of Agent

Address of Agent

I/we hereby appoint the above-named agent as my/our agent and authorize said agent to perform the

following acts on my/our behalf:

(Check all applicable boxes)

Receive my/our tax returns and information

Represent me/us in appeals before the Commis-

regarding my/our returns which have been

sioner of Taxes, including informal conferences

filed with the Department of Taxes

and formal hearings

Represent me/us in informal discussions with

Perform any and all acts on my/our behalf with

Vermont Department of Taxes personnel

respect to the following tax matters:

regarding my/our tax returns and/or liabilities

____________________________________

Negotiate the assessment and payment of

____________________________________

tax liabilities

Special skills or expertise of Agent (i.e., CPA, RPA, Tax Preparer, Attorney-at-Law). If none, write “None”.

This power of attorney is effective for the following tax periods:

It applies to the following taxes:

All prior powers of attorney on file with the Department of Taxes are hereby revoked except:

Signature of person on Line 1

Date

Signature of person on Line 3

Date

CONTINUED ON BACK

Form PA-1(Indiv.)

Rev. 1/07

Form Pa-1 - Special Power Of Attorney (Individual)