Form Pa-1 - Special Power Of Attorney - Individual - 2007
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4Vermont Department of Taxes
133 State Street
Montpelier, VT 05633-1401
Special Power of Attorney
(Individual)
Name
Social Security Number
1
2
Name of Spouse / CU Partner (complete only if power of attorney applicable to joint return)
3
4
Social Security Number of Spouse/CU Partner
Name of Agent
Telephone Number of Agent
5
6
7
Address of Agent
I/we hereby appoint the above-named agent as my/our agent and authorize said agent to perform the
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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”.
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This power of attorney is effective for the following tax periods:
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It applies to the following taxes:
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All prior powers of attorney on file with the Department of Taxes are hereby revoked except:
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Signature of person on Line 1
Date
Signature of person on Line 3
Date
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CONTINUED ON BACK
Form PA-1(Indiv.)
Rev. 1/07
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