Looking for a Illinois Department Of Employment Security Forms And Templates? Download it for free!

Form Le-10 - Power Of Attorney For Representing Employer Under The Illinois Unemployment Insurance Act

State of Illinois

Department of Employment Security 33 South State Street, Chicago, IL 60603-2802

Power of Attorney for Representing Employer under

the Illinois Unemployment Insurance Act

Fax: 312-793-6296

Account No.

Employer

located at

(

)

(Street Address, City, State, Zip Code)

Telephone Number

E-mail Address

Matthew Sanford and Caroline White- OnPay Inc.

hereby authorizes

located at

2300 Lake Park Drive Ste 270

(

877

)

328-6505

(Street Address, City, State, Zip Code)

Telephone Number

E-mail Address

to represent the Employer before the Director in any and all matters, to act in the Employer’s stead with the same

consequences as the Employer, and to receive any and all information requested by said Representative pertaining to

the Employer’s liability for the payment of contributions, interest and penalties under the Illinois Unemployment

Insurance Act, until such time as the appointment is terminated. I understand that my Representative shall be provided

information only to the extent that it is requested for one of the purposes set forth in Section 1900 of the Illinois

Unemployment Insurance Act [820 ILCS 405/1900].

Signature

Name of Employer

Title

Date

LE-10 (Rev. 3/13)

Page 1 of 1

Form Le-10 - Power Of Attorney For Representing Employer Under The Illinois Unemployment Insurance Act