Form Ul-1 M - Unemployment Insurance Special Mailing Form (Page 2 of 2) in pdf

Form Ul-1 M - Unemployment Insurance Special Mailing Form Page 2

STATE OF ILLINOIS

DEPARTMENT OF EMPLOYMENT SECURITY

REVENUE DIVISION

401 SOUTH STATE STREET

CHICAGO, ILLINOIS 60605-2280

Account No. _______________

POWER OF ATTORNEY FOR REPRESENTING EMPLOYER

BEFORE THE DIRECTOR OF EMPLOYMENT SECURITY

UNDER THE ILLINOIS UNEMPLOYMENT INSURANCE ACT

KNOW ALL MEN TO THESE PRESENTS, That the employer, __________________________________________________

Name

________________________________________________________________________________________________________

State whether individual, partnership or corporation, etc.

located at _________________________________________________________________________________________________

Address

has made, constituted and appointed, and by these presents does hereby make, constitute and appoint Representative,

________________________________________________________________________________________________________

Name and Address

as attorney(s)-in-fact for the employer, to represent the employer before the Director of Employment Security of the State of Illinois,

in any and all matters, proceedings and hearings pertaining to the employer’s liability for the payment of contributions, interest and

penalties under The Illinois Unemployment Insurance Act.

Giving and granting unto the employer’s said representative, full power and authority to do and perform all and every act and thing

whatsoever requisite, necessary and proper to be done, in and about the premises as fully to all intents and purposes as the employer

might or could do, hereby ratifying and confirming all that the employer’s said attorney shall lawfully do or cause to be done by

virtue hereof. This Power of Attorney can be used to change the mailing addresses of only the documents specified on the reverse

side of this form. Unless the reverse side of this form is completed, no documents will be sent to the address designated on the

Power of Attorney. However, all documents other than those specified by the Department on the reverse side will be mailed to the

employer’s last known place of business.

Dated at _________________________________ , this ______ day of ____________________ , __________.

_____________________________________________________

Name of Employer

Subscribed and sworn to me this

By __________________________________________________

Signature

______ day of______________

Title _________________________________________________

__________________________

Notary Public

Form Ul-1 M - Unemployment Insurance Special Mailing Form Page 2