Vermont § 4051 - Statutory form power of attorney 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.

§ 4051. Statutory form power of attorney 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 ( ) Create, amend, or change rights of survivorship ( ) 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: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ 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: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ 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