Power Of Attorney Form - Alaska Department Of Labor And Workforce Development printable pdf download

ALASKA DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

Division of Employment and Training Services – Unemployment Insurance (UI) Tax

1111 W. 8

St., P.O. Box 115509, Juneau, AK 99811-5509

(888) 448-3527 or (907) 465-2757, Fax: (907) 465-2374;

Alaska Relay: (800) 770-8973 or Email:

esd.tax@alaska.gov

POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That

UI account no.

(business name)

Federal ID no.

does hereby constitute and appoint

________________________________________________________________

(designated authority)

________________________________________________________________

(designated authority mailing address)

________________________________________________________________

City

State

Zip code

________________________________________________________________

Phone

Fax

its true and lawful attorney in fact with full power and authority to represent said company before the Alaska

Department of Labor and Workforce Development, Division of Employment and Training Services effective

immediately and until this authority has been revoked in writing in connection with any and all Unemployment

Insurance matters as indicated below. For areas you would like this Power of Attorney to apply, check either “New”

or “Add.” “New” will supersede previous Powers of Attorney for lines checked. “Add” does not supersede previous

Powers of Attorney for lines checked.

New Add

1. Filing of completed forms, including claims for refund or adjustment of account, liability or status

determinations and wage record reports

2. Receipt of Tax Rate Notices (TR02)

3. Payment of contributions and any penalties and interest assessed on the account

4. Discuss matters affecting the experience record and contribution rate of the employer account

5. Discuss all matters affecting any adjustments to the employer’s account

6. Enroll in the State Information Data Exchange System (SIDES) for electronic:

Notification of Separation information

Wage Earnings Audits

Contact name:

Phone:

Email:

7. All matters and forms affecting UI benefits, job separation information, hearing notices and decisions

8. Reporting agency: Discuss rates, submit Supplemental reports/payments, obtain IRS certifications

IN WITNESS WHEREOF, the said

(owner, officer or member)

has caused this instrument to be duly attested by the signature of its duly qualified officer this

day of

, 20____.

Printed name

Title and company:

(employer signature):

STATE: _______________ COUNTY OF______________________________, __________________, 20______

Then, personally appeared the above named____________________________________________ whose

title is____________________________________ and acknowledged the foregoing instrument to be his/her free

act and deed in his/her said capacity.

Notary public

Type or print name

My commission expires

Rev. 8/17

Power Of Attorney Form - Alaska Department Of Labor And Workforce Development

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