Power Of Attorney Form - Alaska Department Of Labor And Workforce Development printable pdf download

ALASKA DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Employment Security Division – Unemployment Insurance (UI) Tax

1111 W. 8

Street, P.O. Box 115509, Juneau, AK 99811-5509

1-888-448-3527 or (907) 465-2757, Fax: (907) 465-2374;

TTY/TDD: 1-800-770-8973 or E-mail address: esd_tax@labor.state.ak.us

POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That

________________________________________________

UI Account No

. _______________

(business name)

. ________________

Federal ID No

having its principal office at

__________________________________________

(business mailing address)

____________________________________

City

State

Zip Code

does hereby constitute and appoint __________________________________________________________

(designated authority)

__________________________________________________________

(designated authority mailing address)

__________________________________________________________

City

State

Zip Code

__________________________________________________________

Phone

Fax

its true and lawful attorney in fact with full power and authority to represent said company before the Alaska

Department of Labor and Workforce Development, Employment Security Division effective immediately and until

this authority has been revoked in writing in connection with any and all unemployment insurance matters as

indicated below:

[ ]

1. Filing of completed forms, including claims for refund or adjustment of account, liability or status

determinations and wage record reports.

[ ] 2. Receipt of blank Quarterly Contribution Report Form (TQ01)

[ ] 3. Receipt of Tax Rate Notices (TR02)

[ ] 4. Payment of contributions and any penalties and interest assessed on the account.

[ ] 5. Discuss matters affecting the experience record and contribution rate of the employer account.

[ ]

6. Discuss all matters affecting any adjustments to the employer’s account.

[ ] 7. All matters and forms affecting UI benefits, job separation information, hearing notices and decisions.

IN WITNESS WHEREOF, the said________________________________________________________

(owner, officer or member)

has caused this instrument to be duly attested by the signature of its duly qualified officer this__________ day

of_____________________, 20____. This authorization cancels and supersedes all prior authorizations for

authority indicated in areas 1 through 7 above.

Company Name:

Title:

( employer signature):

______________

_____________________________, _________________,

______

STATE:

COUNTY OF

Then, personally appeared the above named____________________________________________ whose

title is____________________________________ and acknowledged the foregoing instrument to be his/her free

act and deed in his/her said capacity.

Notary Public

Type or Print Name

My Commission Expires

rev 05/12)

Power Of Attorney Form - Alaska Department Of Labor And Workforce Development

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