Employer'S Representative Authorization (Page 2 of 3) in pdf

Employer'S Representative Authorization Page 2

Section II - Authorization for Representation or Dissolution of Representation

I hereby authorize the Ohio Department of Job and

I am hereby notifying the Ohio Department of Job

Family Services to allow the above named representative to

and Family Services that I wish to dissolve my

act on my behalf for all matters pertaining to the service

relationship with the above named representative. The

function(s) identified in Section III.

Ohio Department of Job and Family Services should no

longer allow the above named representative to act on

NOTE: If correspondence should be sent on a regular basis

my behalf for matters pertaining to the service

to the Representative, please choose representative for

function(s) identified in Section III or send them any

question #1.b in Section III.

information pertaining to my account.

Section III - Service Function and Correspondence

1.a To what service function(s) does the authorization or

1.b For the service function(s) selected in question #1 a, where

dissolution selected in Section II apply?

should the correspondence be sent on a regular basis?

(Please check all that apply)

(Choose only one per service function)

Representative or

Tax Manage Account Demographics

Employer

Third Party Administrator

Representative or

Tax Manage Account Status

Employer

Third Party Administrator

Representative or

Tax Reporting and Payments

Employer

Third Party Administrator

Representative or

Tax Monetary Transactions

Employer

Third Party Administrator

Representative or

Tax Appeals and Waivers

Employer

Third Party Administrator

Representative or

Tax Audits

Employer

Third Party Administrator

Section IV - Signature

I hereby acknowledge that by signing this document that I relieve the Ohio Department of Job and Family Services from any liability

arising from the exercise of rights and causes of action on account of or growing out of failure of the undersigned to receive any

correspondence sent to the representative as indicated in Section III, including but not limited to:

1. Notification required by Section 4141.26

2. Injury caused by untimely appeal

This authorization, voluntarily given by the undersigned, shall remain in full force and effect until such time as the agency is notified

in writing by the undersigned or by the designated representative that the relationship has been dissolved.

Employer Signature

NOTE Must be owner, partner, member or corporate officer

Title:

Employer

sign your

name

Date:

Enter

here.

the date

here.

Page 2 of 3

JFS 20106 (9/2010)

Employer'S Representative Authorization Page 2

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