Employer'S Representative Authorization printable pdf download

Employer'S Representative Authorization

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES

P.O. BOX 182404

Columbus, Ohio 43218-2404

(614) 466-2319

FOR 0006

EMPLOYER'S REPRESENTATIVE AUTHORIZATION

To immediately authorize a representative (third party administrator, accountant, payroll company, etc) to act on your behalf or to

receive correspondence regarding your account immediately, please visit our website at

anytime of the

day or night. If you prefer, you may submit your information by completing this form and your account will be updated within 2-3 weeks.

When completing this form, please print using block capital letters in black ink. For example:

Section I -

Employer and Representative Information

NOTE: To notify ODJFS that you have given power of attorney to another individual, please complete a Power of

Attorney form (JFS 20107).

Employer Name

Employer

print your

name

here.

Employer Account Number

Plant Number (If none, please leave blank)

Employer Phone Number

Employer

write your

phone

number

Representative or Third Party Administrator Name

here.

A C U M E N

F I S C A L

A G E N T

L L C

Representative or Third Party Administrator Number

Representative or Third Party Administrator Phone Number

8 6 6

8 6 2

6 8 6 2

Representative Address Line 1 - Enter street address or PO Box information here (ie, 123 Main St, PO BOX 123, etc.).

4 5 4 2

I N V E R N E S S

A V E

Representative Address Line 2 - Enter secondary address information here (ie, STE 123, APT A, 1st FL, etc.). If none, please leave blank.

S T E

2 1 0

City

M E S A

State

ZIP

Country

United States

8 5 2 0 6

Postal Delivery Code – International addresses only

Province - International addresses only

Page 1 of 3

JFS 20106 (9/2010)

Employer'S Representative Authorization

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