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

MAINE DEPARTMENT OF LABOR

Bureau of Unemployment Compensation – Tax Division

45 Commerce Drive, P.O. Box 259

Augusta, ME 04332-0259

POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That_____________________________________________________________________________

(owner or member)

UI Account No._______________________of__________________________________________________

(business name)

does hereby constitute and appoint___________________________________________________________

(designated authority)

___________________________________ its true and lawful attorney in fact with full power and authority to

represent _______________________________________________________________________________

(business name)

before the Maine Department of Labor, Bureau of Unemployment Compensation, effective immediately and

until this authority has been revoked in writing in connection with any and all matters as indicated below:

[ ] 1. The filing of completed forms, including claims for refund or adjustment of account, employer’s appeal

of benefit claims, assessments, liability or status determinations, contribution rate, wage record

reports and related information.

[ ] 2. The payment of contributions and any penalties and interest assessed on the account.

[ ] 3. The obtaining 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 account.

[ ] 5. The discussion of any or all of the foregoing with authorized agents of the Maine Department of Labor,

Bureau of Unemployment Compensation.

IN WITNESS WHEREOF, the said________________________________________________________

(owner or member)

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

of_____________________, 20____.

Company Name

Title

STATE:_____________________

COUNTY OF_____________________________,

_________________________________, 20______

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

QUESTIONS ABOUT THIS NOTICE? Contact the Status Unit at (207) 621-5120

Fax: (207) 287-3733; TTY (Deaf / Hard of Hearing): 1-800-794-1110

Me. UC-28 (rev. 09/07)

E-mail address: division.uctax@Maine.gov

Form Me. Uc-28 - Power Of Attorney

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