Form Ia 900 - Power Of Attorney Form
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1
2New York State Department of Labor
For office use only
Unemployment Insurance (UI) Division
POA #:
Initials:
Power of Attorney
Read the Instructions for Filing a Power of Attorney, (IA 900.1), before you complete this form. They:
•
Explain how to complete this form and
•
Define the extent of the powers being granted
1. Employer information
Employer legal name
UI Employer Registration Number
Mailing address
Federal Identification Number
City, village, town or post office
State
Zip code
2. Power of Attorney (POA) information (List only one POA per form)
Firm name
Contact name
Mailing address
Phone and fax numbers
I appoint the above named to represent me for the following designated purposes:
a)
All UI matters
Check this box if you checked box a) above and want your mail sent to the POA address listed above
b)
UI matters limited to contribution rates, elements used to calculate UI rates and under/overpayment information
c)
Filing agent matters limited to contribution rates and account under/over payment information
d)
UI benefit claim matters limited to information specific to a claim for UI benefits filed against my UI employer account
e)
UI matters limited to acting on my behalf with a UI Employer Services Representative regarding audits,
investigations and enforcement actions
f)
UI matters limited to acting on my behalf for UI Administrative Proceedings and Court Appeals
My representative is also authorized to receive disclosures of, and review and inspect confidential Federal tax information
and to perform any and all acts that I (we) can perform with respect to those tax matters as they bear on unemployment
insurance matters.
Note: Confidential Federal tax information shall include any and all information provided to the Department by the Internal
Revenue Service.
3. Retention/Revocation of prior power(s) of attorney
Filing this power of attorney automatically revokes all existing power(s) of attorney with any representatives authorized for
the same designated purposes with the UI Division. Previously filed power(s) of attorney for other designated UI purposes
remain in effect with this Division unless you revoke them in writing.
4. Employer’s signature
If the employer named above is other than an individual: I certify that I am acting in the capacity of a corporate officer, partner
(except a limited partner), member or manager of a limited liability company, or fiduciary on behalf of the employer. I have the
authority to execute this power of attorney on behalf of the employer. If the matter concerns an individual proprietorship the
owner must sign. If the matter concerns a partnership, LLP, LLC, corporation or other entity the individual signing the consent
must have the authority to bind the entity. If signed by a corporate officer, partner, member, guardian, tax matters partner,
executor, receiver, administrator, or trustee on behalf of the employer, I certify that I have the authority to execute this form on
behalf of the employer.
Signature
Employer’s phone and fax numbers
Date
Print the name of the person signing this form if not the employer(s) named above
Title, if applicable
Affix corporate seal if applicable
IA 900 (09/15)
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