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VERMONT DEPARTMENT OF LABOR ATTN: Employer Services P.O. (ADP)

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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
Taxpayer'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.
Address in Fact: _________________________________
(C-101 Forms, Rate ________________________________
Notices, Statements) ________________________________
Telephone No.: ___________________________________
Client Address: _________________________________
(Only Benefit Claim _______________________________
Related Information) ______________________________
Telephone No.: _________________________________
C-50 (04/16)
(PLEASE COMPLETE PAGE 2)
Fax: 802-828-4248
This Limited Power of Attorney form is effective for the period beginning ________________ and will remain in effect until
this department is otherwise notified.
(Quarter/Year)
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
________________________________________
Signature
______________________________________
Title of Person Signing Power of Attorney
________________________________________
Date
Please specify the client address where benefit claim related information should be mailed.
Clear Form
PRINT
SAVE
ADP, LLC, and its subsidiaries and Corporate Cost
Control, LLC. (ADP Unemployment Claims).
PO Box 1390
LONDONDERRY NH 03053-1390
855-537-8536
PO Box 1390
LONDONDERRY NH 03053-1390
855-537-8536
ATTESTATION OF AGENT
I, _____________________________________ do hereby attest that I accept appointment as agent for
_______________________________________ (hereafter "principal") and:
that I understand my duties under this Limited Power of Attorney and under the law;
that I understand that I have a duty for the principal as to the specific transactions and types of transactions if
expressly required to do so in this Limited Power of Attorney;
that I hereby specifically acknowledge and accept such duties to act in signing this Limited Power of Attorney;
in the case of such a duty to act, my agreement to act on or behalf of the principal is enforceable against me
regardless of whether there is any consideration to support a contractual obligation;
that I understand and acknowledge in signing this Limited Power of Attorney, that if I have been selected as agent
with the expectation that I have special skills or expertise I will use those skills on behalf of the principal.
_____________________________________________ _____________________________
Signature of Agent Date Signed
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
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VERMONT DEPARTMENT OF LABOR ATTN: Employer Services P.O. (ADP)

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Completed 8 February 2021

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