Form 2678 - Employer/payer Appointment Of Agent Page 2
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Form 2678 (Rev. 10-2012)
Page
Part 3:
Agent Information: If you will be an agent for an employer or payer, or want to revoke an appointment, complete this part.
6
Agent’s employer identification number (EIN)
—
7
Agent’s name (not trade name)
8
Trade name (if any)
9
Address
Number
Street
Suite or room number
City
State
ZIP code
Check here if the employer is a home care service recipient receiving home care services through a program administered by a
federal, state, or local government agency.
Under penalties of perjury, I declare that I have examined this form and any attachments, and to the best of my knowledge and belief, it
is true, correct, and complete.
✗
Print your name here
Sign your
name here
Print your title here
/
/
Date
Best daytime phone
2678
Form
(Rev. 10-2012)
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Parent category: Financial