Vermont Department of Taxes, 133 State Street, Montpelier, VT  05633-1401

                                                 Special Power of Attorney                                                                     Form
                                            for use by Individuals, Businesses, Estates and Trusts
                                                                                                                                   PA-1
                                                 (joint filers must each file a Power of Attorney form)

 TAXPAYER
 1.  Name of Taxpayer (Principal)                                                               2. Social Security Number or

    Address of Taxpayer                                                                           Federal ID Number  or        (if applicable) State ID Number

 AGENT
 3.  Name of Agent                                                                              4. Telephone Number of Agent

 5.  Address of Agent

 6.  The Taxpayer hereby appoints the above-named person as agent for the Taxpayer and authorizes said agent to perform the following acts on behalf of the 
     Taxpayer:
     (Check all applicable boxes)
      Receive the Taxpayer’s tax returns and information regarding                 Represent the Taxpayer in appeals before the Commissioner of Taxes at 
       Taxpayer’s returns which have been filed with the Department of               a formal hearing if the agent is an attorney or CPA licensed to practice in 
       Taxes                                                                         the State of Vermont.
      Represent the Taxpayer in discussions and at informal conferences            Prepare and file Vermont state tax returns
       with Vermont Department of Taxes personnel regarding the                     Perform any legal act on the Taxpayer’s behalf with respect to the taxes 
       Taxpayer’s tax returns and/or liabilities                                     and tax periods identified below
      Negotiate the assessment and payment of tax liabilities

  7.  This power of attorney is effective for the following taxes and tax periods: 

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

 9.  All prior powers of attorney on file with the Department of Taxes are herby revoked except:

 SIGNATURE
 10.  Signature of Individual Taxpayer on Line 1                                                                  Date

 11.  Signature of person authorized to sign for Entity Taxpayer Date                12.  Printed name and title of person signing POA for Entity Taxpayer

                                                                 ATTESTATION OF AGENT
     I hereby attest that:
     •  I accept appointment as agent for the Taxpayer;
     •   I understand my duties under this Power of Attorney and under law;
     •   I understand that I am expected to use the skills and expertise identified above on behalf of the Taxpayer.

 13.  Signature of Agent (person on Line 3)                                                                       Date

                                                                                                                                                Form PA-1
                                                                                                                                                Rev. 09/13

  INSTRUCTIONS FOR COMPLETING VERMONT DEPARTMENT OF TAXES
                                    SPECIAL POWER OF ATTORNEY (POA).

• This form may be used by individuals, businesses, estates and trusts. Joint income tax filers must each complete and file 
  a power of attorney form.

• All POA forms submitted to the Department of Taxes must comply with the requirements of chapter 123 of Title 14, 
  except that signatures of a witness and notary are not required.

• POA forms must be signed by the agent.  THE DEPARTMENT OF TAXES WILL NOT ACCEPT A POA UNLESS 
  SIGNED BY THE AGENT.

• By signing, an agent attests that he/she accepts appointment as agent and understands the duties of agent, both under the 
  POA and under the law.  In addition, if special skills or expertise of the agent are identifed, the agent must attest that he/
  she understands that he/she is expected to use those skills and expertise on behalf of the Taxpayer.

                                 LINE-BY-LINE INSTRUCTIONS FOR SPECIAL POA

1.  Print the name and address of the Taxpayer.                   act on your behalf.  If all taxes and tax periods, write 
                                                                  “ALL”.
2.  Enter  the  Social  Security  Number  of  an  individual 
  Taxpayer or Federal ID Number or (if applicable) State         8.  Identify any special skills or expertise of Agent which 
  ID Number of an entity Taxpayer.                                will be exercised by agent on behalf of Taxpayer, such 
                                                                  as CPA, RPA, tax preparer, attorney-at-law.  If none, 
3.  Print the name of the Agent.                                  write “NONE”.

4.  Print the telephone number of the Agent.                     9.  List  any  prior  Powers  of  Attorney  on  file  with  the                                  
5.  Print the address of the Agent.                               Department of Taxes which are NOT revoked.

6.  Check applicable boxes if you are authorized to prepare      10.  Signature of person on Line 1 if an individual Taxpayer.

  and file Vermont state tax returns, the returns must still     11.  Signature of person signing for an entity Taxpayer.
  be signed by the taxpayer.
                                                                 12.  Print the name and title of person signing for an entity 
7.  List  specific  tax  types  (i.e.,  “income  tax”)  and  tax  taxpayer.
  periods (i.e., “2002”) for which Agent is authorized to 
                                                                 13.  Signature of Agent and date agent signed.