Form 68-0092 - Declaration Of Power Of Attorney Or Authorized Representative - Iowa Workforce Development Unemployment Insurance (Ui) Tax Bureau

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ACCOUNT NUMBER
FORM NUMBER
DOCUMENT CONTROL DATE
68-0092
0
0
0
DESCRIPTION
DESCRIPTION (CONTINUED)
FOR ADMINISTRATIVE
USE ONLY
IOWA WORKFORCE DEVELOPMENT UNEMPLOYMENT INSURANCE (UI) TAX BUREAU
Declaration of Power of Attorney or Authorized Representative -
68-0092 (05-07)
1. Provide Employer/Company Information
Legal Name of Business or Last Name of Sole Proprietor
First Name of Sole Proprietor
Initial
Federal Identification Number
Social Security Number
Iowa UI Tax Account Number
DBA Name
Current Mailing Address
Telephone Number
City
State
Zip Code + 4
Employer's E-Mail Address
2. Provide Power of Attorney or Authorized Representative Information
Name of Firm or Company's Legal Name
Federal Identification Number
Name (if Firm is not designated)
Telephone Number
Fax Number
Address
City
Zip Code + 4
State
Employer's E-Mail Address of Power of Attorney or Authorized Representative
Check appropriate box. Refer to instructions for explanation of privileges.
Power of Attorney
Authorized Representative
As the true and lawful agent, with limited power and authority to represent the said employer before Iowa Workforce Development, until further notice, in only
the matters selected below: (Please check all pertinent boxes)
All Unemployment Insurance matters
All Tax related matters
All Claims/Benefits related matters.
Filing - Unemployment Insurance Reports and payments

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