Vt. Stat. tit. 14 § 4051
A document substantially in the following form may be used to create a statutory form power of attorney that has the meaning and effect prescribed by this chapter.
VERMONT STATUTORY FORM POWER OF ATTORNEY IMPORTANT INFORMATION
This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in the Vermont Uniform Power of Attorney Act, 14 V.S.A. chapter 127.
This power of attorney does not authorize the agent to make health-care decisions for you.
You should select someone you trust to serve as your agent. Unless you specify otherwise, generally the agent's authority will continue until you die or revoke the power of attorney or the agent resigns or is unable to act for you. Your agent is entitled to reasonable compensation unless you state otherwise in the Special Instructions.
This form does not revoke powers of attorney previously executed by you unless you initial the introductory paragraph under DESIGNATION OF AGENT that all previous powers of attorney are revoked.
This form provides for designation of one agent. If you wish to name more than one agent, you may name a coagent in the Special Instructions. Coagents are not required to act together unless you include that requirement in the Special Instructions.
If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent.
This power of attorney becomes effective immediately unless you state otherwise in the Special Instructions.
If you have questions about the power of attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.
DESIGNATION OF AGENT
I _______________ (Name of Principal) () revoke all previous powers of attorney and name the following person as my agent:
Name of Agent: ______________________________________________
Agent's Address: _____________________________________________
Agent's Telephone Number: ____________________________________
DESIGNATION OF SUCCESSOR AGENT(S) (OPTIONAL)
If my agent is unable or unwilling to act for me, I name as my successor agent:
Name of Successor Agent: _______________________________________
Successor Agent's Address: ______________________________________
Successor Agent's Telephone Number: _____________________________
If my agent is unable or unwilling to act for me, I name as my second successor agent:
Name of Second Successor Agent: _________________________________
Second Successor Agent's Address:________________________________
Second Successor Agent's Telephone Number:_______________________
GRANT OF GENERAL AUTHORITY
I grant my agent and any successor agent general authority to act for me with respect to the following subjects as defined in the Vermont Uniform Power of Attorney Act, 14 V.S.A. chapter 127, together with the incidental powers enumerated in section 4033 of that chapter.
( STRIKE THROUGH each subject you DO NOT want to include in the agent's general authority. )
Real Property
Tangible Personal Property
Stocks and Bonds
Commodities and Options
Banks and Other Financial Institutions
Operation of Entity or Business
Insurance and Annuities
Estates, Trusts, and Other Beneficial Interests
Claims and Litigation
Personal and Family Maintenance
Benefits from Governmental Programs or Civil or Military Service
Retirement Plans
Taxes
GRANT OF SPECIFIC AUTHORITY (OPTIONAL)
My agent MAY NOT do any of the following specific acts for me UNLESS I have INITIALED the specific authority listed below:
(CAUTION: Granting any of the following will give your agent the authority to take actions that could significantly reduce your property or change how your property is distributed at your death. INITIAL ONLY the specific authority you WANT to give your agent.)
() An agent who is not an ancestor, spouse, or descendant may exercise authority under this power of attorney to create in the agent or in an individual to whom the agent owes a legal obligation of support an interest in my property whether by gift, rights of survivorship, beneficiary designation, disclaimer, or otherwise
() Create, amend, revoke, or terminate an inter vivos, family, living, irrevocable, or revocable trust
() Consent to the modification or termination of a noncharitable irrevocable trust under 14A V.S.A. § 411
() Make a gift, subject to the limitations of 14 V.S.A. § 4047 (gifts) and any special instructions in this power of attorney
() Consent to the modification or termination of a noncharitable irrevocable trust under 14A V.S.A. § 411
() Create, amend, or change a beneficiary designation
() Waive the principal's right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan
() Exercise fiduciary powers that the principal has authority to delegate
() Authorize another person to exercise the authority granted under this power of attorney
() Disclaim or refuse an interest in property, including a power of appointment
() Exercise authority with respect to elective share under 14 V.S.A. § 319
() Exercise waiver rights under 14 V.S.A. § 323
() Exercise authority over the content and catalogue of electronic communications and digital assets under 14 V.S.A. chapter 125 (Vermont Revised Uniform Fiduciary Access to Digital Assets Act)
() Exercise authority with respect to intellectual property, including, without limitation, copyrights, contracts for payment of royalties, and trademarks
() Convey, or revoke or revise a grantee designation, by enhanced life estate deed pursuant to 27 V.S.A. chapter 6 or under common law.
LIMITATION ON AGENT'S AUTHORITY
An agent who is not my ancestor, spouse, or descendant MAY NOT use my property to benefit the agent or a person to whom the agent owes an obligation of support unless I have included that authority in the Special Instructions.
WHEN POWER OF ATTORNEY EFFECTIVE
This power of attorney becomes effective when executed unless the principal has initialed one of the following:
() This power of attorney is effective only upon my later incapacity. OR
() This power of attorney is effective only upon my later incapacity or unavailability. OR
() I direct that this power of attorney shall become effective when one or more of the following occurs:
_______________________________________________________________
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EFFECTIVE DATE
This power of attorney is effective immediately unless I have indicated or stated otherwise in the section above entitled When Power of Attorney Effective or in the section below entitled Special Instructions.
SPECIAL INSTRUCTIONS (OPTIONAL)
You may give special instructions on the following lines:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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NOMINATION OF GUARDIAN (OPTIONAL)
If it becomes necessary for a court to appoint a guardian of my estate or a guardian of my person, I nominate the following person(s) for appointment:
Name of Nominee for [conservator or guardian] of my estate: ___________
Nominee's Address: ____________________________________________
Nominee's Telephone Number: ___________________________________
Name of Nominee for guardian of my person: ________________________
Nominee's Address: ____________________________________________
Nominee's Telephone Number: ___________________________________
RELIANCE ON THIS POWER OF ATTORNEY
Any person, including my agent, may rely upon the validity of this power of attorney or a copy of it unless that person knows it has terminated or is invalid. Unless expressly stated otherwise, this power of attorney is durable and shall remain valid if I become incapacitated or unavailable.
SIGNATURE AND ACKNOWLEDGMENT
Your Name Printed: ____________________________________________
Your Address: _________________________________________________
Your Telephone Number: ________________________________________
State of: ______________________________________________________
County of: ____________________________________________________
This document was acknowledged before me on: _________________ (Date)
by ________________________________. (Name of Principal)
(Seal, if any): __________________________________________________
Signature of Notary: _____________________________________________
My commission expires: _________________________________________
IMPORTANT INFORMATION FOR AGENT
Agent's Duties
When you accept the authority granted under this power of attorney, a special legal relationship is created between you and the principal. This relationship imposes upon you legal duties that continue until you resign or the power of attorney is terminated or revoked. You must:
Unless the Special Instructions in this power of attorney state otherwise, you must also:
Termination of Agent's Authority
You must stop acting on behalf of the principal if you learn of any event that terminates this power of attorney or your authority under this power of attorney. Events that terminate a power of attorney or your authority to act under a power of attorney include:
Liability of Agent
The meaning of the authority granted to you is defined in the Vermont Uniform Power of Attorney Act, 14 V.S.A. chapter 127. If you violate the Vermont Uniform Power of Attorney Act, or act outside the authority granted, you may be liable for any damages caused by your violation. In addition to civil liability, failure to comply with your duties and authority granted under this document could subject you to criminal prosecution.
If there is anything about this document or your duties that you do not understand, you should seek legal advice.
14 V.S.A. § 4051