Power Of Attorney Authorization Form

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Department of Labor, Licensing and Regulation
Division of Unemployment Insurance
Power of Attorney Authorization Form
Employer/Taxpayer
1. Maryland Unemployment Insurance Account Number: ______________________________
2. Federal Employer Identificaion Number: __________________________________________
3. Name of Employer/Taxpayer: __________________________________________________
4. Address: ___________________________________________________________________
___________________________________________________________________________
Reporting Agent
1. Name of Reporting Agent:____________________________________________________
2. Address: ___________________________________________________________________
___________________________________________________________________________
3. Telephone Number: __________________________________________________________
Authorization
Check the authorization that is granted to the Reporting Agent. (Check all that apply.)
1. [ ] File, sign and date the quarterly unemployment insurance contribution/employment
report
2. [ ] Make payments on behalf of the employer/taxpayer
3. [ ] Receive and respond to confidential information regarding quarterly contributions and
tax rates.
4. [ ] Receive and respond to confidential information regarding unemployment insurance
claims filed by employees of the employer/taxpayer
Effective Date of Authorization
______________________________
Name and Signature of Employer/Taxpayer
_________________________
Name
_______________________
___________________________
____________
Signature
Title
Date
Submit to: Maryland Unemployment Insurance
Refer Questions to: 410-767-3223
Employer Status Unit
FAX: 410-767-2848
1110 N. Eutaw St., Room 409
Email: status@dllr.state.md.us
Baltimore, Maryland 21201

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