Looking for a North Carolina Legal Forms And Templates? Download it for free!

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

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;

REVISED 2-20-96

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