Power Of Attorney Authorization Form printable pdf download

Power Of Attorney Authorization Form

Department of Labor, Licensing and Regulation

Division of Unemployment Insurance

Power of Attorney Authorization Form

Employer/Taxpayer

1. Maryland Unemployment Insurance Account Number: ______________________________

2. Federal Employer Identificaion Number: __________________________________________

3. Name of Employer/Taxpayer: __________________________________________________

4. Address: ___________________________________________________________________

___________________________________________________________________________

Reporting Agent

1. Name of Reporting Agent:____________________________________________________

2. Address: ___________________________________________________________________

___________________________________________________________________________

3. Telephone Number: __________________________________________________________

Authorization

Check the authorization that is granted to the Reporting Agent. (Check all that apply.)

1. [ ] File, sign and date the quarterly unemployment insurance contribution/employment

report

2. [ ] Make payments on behalf of the employer/taxpayer

3. [ ] Receive and respond to confidential information regarding quarterly contributions and

tax rates.

4. [ ] Receive and respond to confidential information regarding unemployment insurance

claims filed by employees of the employer/taxpayer

Effective Date of Authorization

______________________________

Name and Signature of Employer/Taxpayer

_________________________

Name

_______________________

___________________________

____________

Signature

Title

Date

Submit to: Maryland Unemployment Insurance

Refer Questions to: 410-767-3223

Employer Status Unit

FAX: 410-767-2848

1110 N. Eutaw St., Room 409

Email: status@dllr.state.md.us

Baltimore, Maryland 21201

Power Of Attorney Authorization Form