Form Poa (Rev. 09/16) - Power Of Attorney / Authorization Of Agent Form printable pdf download

Form Poa (Rev. 09/16) - Power Of Attorney / Authorization Of Agent Form

DWS-UI

UTAH DEPARTMENT OF WORKFORCE SERVICES

Form POA

Rev. 09/16

Unemployment Insurance

P.O. Box 45288

Salt Lake City, Utah 84145-0288

Fax (801) 526-9377

POWER OF ATTORNEY / AUTHORIZATION OF AGENT FORM

KNOW ALL MEN BY THESE PRESENTS:

THAT THE UNDERSIGNED,

Federal Identification Number:

( corporation, partnership, individual )

State Identification Number:

State:

Having its principal office at:

Does hereby constitute and appoint:

( Agent legal name )

its divisions and subsidiaries the true and lawful attorneys-in-fact of the undersigned, until further written notice, to

represent the undersigned before any and all government bodies, agencies or instrumentalities, in all matters

affecting unemployment insurance taxes including, without limitation, the following:

( Check and complete all applicable types )

Unemployment tax matters

Agent Address

Agent City, State and Zip

Agent Telephone

Check this box to send new correspondence to the above address.

Unemployment claims matters (determinations, hearing notices, appeals, benefit

charges)

Agent Address

Agent City, State and Zip

Agent Telephone

Check this box to send new correspondence to the above address.

Each of said attorneys-in-fact shall have the power to act with or without the others and the power authority to

perform, in the name and on behalf of the undersigned, every act necessary to carry out the subject matter hereof

as fully as the undersigned could do. The undersigned hereby ratifies and approves the acts of said

attorneys-in-fact. The services to be performed shall specifically exclude any which now or in the future may be

deemed to be the practice of law.

Form Poa (Rev. 09/16) - Power Of Attorney / Authorization Of Agent Form