Employment Security Commission Of North Carolina Power Of Attorney And Declaration Of Representative

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EMPLOYMENT SECURITY COMMISSION OF NORTH CAROLINA
POST OFFICE BOX 26504
RALEIGH, NC 27611-6504
POWER OF ATTORNEY
AND
DECLARATION OF REPRESENTATIVE
EMPLOYER NAME (Exactly as shown on Employer Security Commission Records)
FEDERAL EMPLOYER IDENTIFICATION NUMBER
STATE UNEMPLOYMENT TAX ACCOUNT NUMBER
REPRESENTATIVE NAME
The above representative is hereby appointed to represent employer in all matters pertaining to
contributions (tax) and benefits (claims) until further notice. This representation includes:
1. Completing and delivering all forms for filing Employer’s Tax and Wage Reports,
claims for refunds, or adjustments;
2. To complete and respond to benefit claims including but not limited to the completion
of Form NCUI 500AB and providing information relative thereto;
3. Authorization to send to the representative notices in matters regarding contributions
(tax) and benefits (claims);
4. All matters affecting the tax rate, contributions (tax), and/or direct reimbursements;
5. The personal discussion of any and all of the foregoing with proper officials of the
Employment Security Commission of North Carolina;
6. The initial Application for Review and Redetermination of the employer’s tax rate;
7. This Power of Attorney and declaration of Representative revokes all earlier reporting
representative authorizations and Powers of Attorney issued by the undersigned
employer;

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