Form De 48 - Power Of Attorney (Poa) Declaration
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1
2POWER OF ATTORNEY (POA) DECLARATION
SEE INSTRUCTIONS ON THE BACK OF THIS FORM.
I. EMPLOYER/TAXPAYER INFORMATION
(please type or print)
California Employer Account Number:
Taxpayer Identification Number:
Federal Employer Identification Number:
(if applicable)
Owner/Corporation Name:
Social Security Number (SSN)/Corporate Identification Number:
Business Name/Doing Business As (DBA):
Business Mailing Address:
City:
State
ZIP Code
Business Phone Number:
Business Fax Number:
Business Location (if different from above):
City:
State
ZIP Code
II.
REPRESENTATIVE DESIGNATION
I hereby appoint the following person to represent the employer/taxpayer for specified tax matters arising under
the California Unemployment Insurance Code.
Representative’s Business:
Representative’s Name:
Phone Number:
Fax Number:
Business Mailing Address:
City:
State
ZIP Code
III.
AUTHORIZED ACT(S)
GENERAL AUTHORIZATION: If you want to give the representative general authority to perform all acts on your
behalf with regard to your state tax matters.
SPECIFIC DECLARATION:
If you want to give the representative limited authority with regard to your state
From
To
tax matters, indicate the specific dates and acts you are authorizing.
To represent the employer/taxpayer for any and all
Tax Reporting
Benefit Reporting
Both
matters relating to the reporting period indicated above.
To represent the employer/taxpayer for changes to their mailing address for any and all
Tax
Reporting
Benefit Reporting
Both matters relating to the reporting period indicated above.
Other acts: (describe specifically)
Subject to revocation, the above representative is authorized to receive confidential information.
IV. SIGNATURE AUTHORIZING POWER OF ATTORNEY
Signature of the employer/taxpayer, owner, officer, receiver, administrator, or trustee for the
employer/taxpayer: If you are a corporate officer, partner, guardian, tax matters partner/person, executor, receiver,
administrator, or trustee on behalf of the employer/taxpayer, you are certifying that you have the authority to execute
this form on behalf of the employer/taxpayer by signing this Power of Attorney Declaration.
If this Power of Attorney Declaration is not signed and dated, it will be returned as invalid.
Signature
Title (Owner, Partner, Corp. Officer: Pres., Vice Pres., CEO or CFO)
Print Name
SSN
Date
DE 48 Rev. 7 (5-13) (INTERNET)
Page 1 of 2
CU
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