Pennsylvania Unemployment Compesation - Power Of Attorney (Uc-884) printable pdf download

Pennsylvania Unemployment Compensation

POWER OF ATTORNEY

Know all men by these present, that I, ___________________________________________________________________________,

(EMPLOYER'S NAME)

L L

L L L L L

L L

L L L L L L L,

—

Account No.

, FEIN

a _________________________________________________, having my principal office at_________________________________

(TYPE OF ENTITY)

_______________________________________________________________________________________________________________________________,

(EMPLOYER'S BUSINESS ADDRESS, CITY, STATE AND ZIP CODE)

______________________________________________________________________________________________________________________________________,

(EMPLOYER'S MAILING ADDRESS, IF DIFFERENT THAN ABOVE)

do hereby make, constitute and appoint ______________________________________________________________________________,

(ATTORNEY-IN-FACT NAME)

________________________________________________________________________________________________________________________________________,

(ATTORNEY-IN-FACT MAILING ADDRESS, CITY, STATE AND ZIP CODE)

my true and lawful attorney-in-fact with full power and authority to represent me before, and act on my behalf with, the —

1. L Office of Unemployment Compensation Tax Services, in any matter(s) relating to my liability for unemployment compensation

contributions.

A. L Also, I authorize the Office of Unemployment Compensation Tax Services to change my mailing address in its

records to the address of said attorney-in-fact. (This will result in mailings of quarterly UC tax returns, tax

rate notices, and miscellaneous tax notices, including deficiency notices, to be sent to the attorney-in-fact.)

2. L Bureau of Unemployment Compensation Benefits and Allowances, in any matter(s) relating to unemployment com-

pensation benefit payments.

A. L Also, I authorize the Bureau of Unemployment Compensation Benefits and Allowances to change my mailing

address in its records to the address of said attorney-in-fact for:

(1) L monthly notices of compensation charged

(2) L notices of financial determination and associated relief from charge notices

I hereby ratify and confirm all that said attorney-in-fact, or its agents, employees or substitutes shall or may do or cause

to be done by virtue of the power herein conferred until written notice of revocation hereof is received by the Department

of Labor and Industry.

I hereby revoke all prior, inconsistent powers of attorney.

In delegating authority to said attorney-in-fact, for the purposes specified above, it is expressly understood that the

attorney-in-fact and I are equally responsible and each shall incur liability for the penalties provided for false and/or

fraudulent statements or omissions, whether written or oral.

Dated at ____________________________________________________ this _________ day of ________________________ 20 _____.

By: _____________________________________________________

By: __________________________________________________

(SIGNATURE-AUTHORIZED REPRESENTATIVE OF THE EMPLOYER)

(SIGNATURE-AUTHORIZED REPRESENTATIVE OF THE ATTORNEY-IN-FACT)

Title: ___________________________________________________

Title: ________________________________________________

Acknowledged before me this ____________________ day of __________________________________________________ 20 _____

________________________________________________________________

(Seal)

See reverse for instructions and information on completion of this form.

_______________________________________________________________________________________________________________________________________________________________________________________

UC-884

REV 4-04 (Page 1)

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF LABOR AND INDUSTRY

OFFICE OF UC TAX SERVICES

Pennsylvania Unemployment Compesation - Power Of Attorney (Uc-884)

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