Form 68-0092 - Declaration Of Power Of Attorney Or Authorized Representative - Iowa Workforce Development Unemployment Insurance (Ui) Tax Bureau Page 2

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Declaration of Power of Attorney or Authorized Representative - 68-0092 (05-07)

Page 2

3. Provide Additional Power of Attorney or Authorized Representative

Name of Firm or Company's Legal Name

Federal Identification Number

Name (if Firm is not designated)

Telephone Number

Fax Number

Address

City

State

Zip Code + 4

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

Attach a schedule for additional representatives.

Signature of Employer/Corporate Officer, Partner, Member Or Fiduciary

Date

Print Name

Title

IF NOT SIGNED AND DATED, THIS DECLARATION OF POWER OF ATTORNEY OR AUTHORIZED REPRESENTATIVE WILL

NOT BE VALID.