Power Of Attorney And Declaration Of Representative Form 2012 printable pdf download

Power Of Attorney And Declaration Of Representative Form 2012

NORTH CAROLINA DEPARTMENT OF COMMERCE

DIVISION OF EMPLOYMENT SECURITY

POST OFFICE BOX 26504

RALEIGH, NC 27611-6504

POWER OF ATTORNEY

AND

DECLARATION OF REPRESENTATIVE

EMPLOYER NAME (Exactly as shown on the Division of Employment Security 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

Division of Employment Security;

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;

Power Of Attorney And Declaration Of Representative Form 2012