Form Me. Uc-28 - Power Of Attorney - Maine Department Of Labor printable pdf download

MAINE DEPARTMENT OF LABOR

Bureau of Unemployment Compensation

47 State House Station

Augusta ME 04333-0047

POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That

UI Account No.

(Business name)

having its principal office at

Federal ID No.

(Business mailing address)

Telephone

(City)

(State)

(Zip Code)

hereby constitutes and appoints

___________________________________________________________

(Designated authority)

___________________________________________________________

(Designated authority mailing address)

___________________________________________________________

(City)

(State)

(Zip Code)

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

Department of Labor, Bureau of Unemployment Compensation, effective immediately and until this authority

has been superseded by another or has been revoked in writing in connection with any and all unemployment

insurance matters as indicated below.

Please check all that apply

1. Filing of completed forms, including claims for refund or account adjustments, assessments, liability

or status determinations, contribution rate and wage record reports.

2. Payment of contributions and any penalties and interest assessed on the account.

3. Obtaining and discussion of all account information required and authorized by the Maine

Employment Security Law.

4. All matters affecting the experience record and contribution rate of the employer account.

5. Employee wage and separation information and employer’s appeal of benefit claims.

Please confirm and provide the mailing address for Items 6 and/or 7 below.

6. Send a copy of all mailings pertaining to unemployment benefits to:

______________________________________________________________________________

(C/O Name)

(Mailing Address)

(City)

(State)

(Zip Code)

7. Send a copy of all mailings pertaining to unemployment taxes to:

______________________________________________________________________________

(C/O Name)

(Mailing Address)

(City)

(State)

(Zip Code)

IN WITNESS WHEREOF, the said ________________________________________________________

(Signature of 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.

Printed Name of Owner, Officer or Member:

Title:

QUESTIONS ABOUT THIS NOTICE?

Contact a Representative at (207) 621-5120, select option 3; Fax: (207) 287-3733;

TTY (Deaf / Hard of Hearing): 1-800-794-1110; E-mail address:

division.uctax@Maine.gov

Avoid missed mailings and potential late fees by notifying MDOL of any changes to your account.

Me. UC-28 (rev. 07/2011)

Form Me. Uc-28 - Power Of Attorney - Maine Department Of Labor

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