Form Le-10 - Power Of Attorney For Representing Employer Under The Illinois Unemployment Insurance Act Page 2

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UI-1M (Rev. 3/13)
STATE OF ILLINOIS
DEPARTMENT OF EMPLOYMENT SECURITY
33 SOUTH STATE STREET
CHICAGO, IL 60603-2802
UNEMPLOYMENT INSURANCE SPECIAL MAILING FORM
The purpose of this form is to notify the Department of a request to have correspondence sent to an address
other than your business address or to terminate a preexisting address. If the requested address being
added is for a third party or service bureau, you must also complete the Power of Attorney (LE-10)
form.
Fax: 312-793-6296
Employer Name
DBA Name
Illinois UI Account Number
Federal I.D. Number
Note: Each form can be directed to only one address. Therefore, check only once for each form. If your
request cannot be contained in its entirety on this form because of multiple addresses, please provide
of the form:
additional copies
Payroll Center Inc
BIS-32 (Notice to Chargeable Employer)
C/O (Name of Representative or Service Bureau)
x
UI-3/40 (Contribution & Wage Report)
2300 Lake Park Drive Ste 270
Ben-118/118R Benefit Charge Notice
Street Address
Unit or Suite
x
UI-5A/UI5B (Rate Notice)
Smyrna, GA 30080
x
Benefit Appeal Notice
City, State, ZIP
877-328-6505
SI-5 (Notice of Benefit Earnings Audit)
Country
Telephone Number
E-Mail Address
Effective Date
Termination Date
2013
2050
BIS-32 (Notice to Chargeable Employer)
C/O (Name of Representative or Service Bureau)
UI-3/40 (Contribution & Wage Report)
Ben-118/118R Benefit Charge Notice
Street Address
Unit or Suite
UI-5A/UI5B (Rate Notice)
Benefit Appeal Notice
City, State, ZIP
SI-5 (Notice of Benefit Earnings Audit)
Country
Telephone Number
E-Mail Address
Effective Date
Termination Date
Signed by
Date
Title
Telephone Number

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