Form 68-0092 - Declaration Of Power Of Attorney Or Authorized Representative
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1Declaration of Power of Attorney or Authorized Representative
68-0092 (05-10)
1. Business granting Power of Attorney or Authorized Representative
Legal Business Name:
UI Account #:
DBA:
FEIN:
Sole Proprietor Name
(First, MI, Last):
SSN:
Mailing Address 1:
Mailing Address 2:
City:
State/Province:
Zip+4/Postal Code:
Phone:
Ext:
2. Effective dates for Power of Attorney or Authorized Representative
Effective Date:
Through (and including) the Termination Date of:
3. Provide the information of who is receiving Power of Attorney or Authorized Representative
Name of Firm or Legal
Business Name:
FEIN:
Name of Individual:
Agent ID: R
Address 1:
Address 2:
City:
State/Province:
Zip+4/Postal Code:
Phone:
Ext:
Note: If you include more than one party, contact IWD at (888) 848-7442.
4. Indicate which roles will be granted
Will you be granting
Power of Attorney
or
Authorized Representative
As the true and lawful agent, with limited power and authority to represent the said employer before Iowa Workforce Development in only
the matters selected below: (Please check all pertinent boxes)
General Roles:
Website Roles: (This applies to all reporting units)
All Unemployment Insurance matters
All Roles
View Correspondence
Only Claims/Benefits related matters
Update Wage Detail
View Wage Detail
Only Tax related matters
Maintain Account
View Transaction History
Manage Payments
View Payments
Note: If you want to grant privileges based on reporting units, contact IWD at (888) 848-7442.
Date
Authorized Signature
Print Name Here
Title
Phone
Return the signed form to: Iowa Workforce Development
If this form is not signed and dated, this
Unemployment Insurance Tax Bureau
declaration of Power of Attorney or
1000 E Grand Ave
Authorized Representative will not be valid.
Des Moines Iowa 50319-0209
Equal Opportunity Employer/Program
Auxiliary aids & services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
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Parent category: Legal