Form De 48 - Power Of Attorney (Poa) Declaration
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2POWER OF ATTORNEY (POA) DECLARATION
SEE INSTRUCTIONS ON THE BACK OF THIS FORM.
I. EMPLOYER/TAXPAYER INFORMATION
(please type or print)
California Employer Payroll Tax Account
Taxpayer Identification Number:
Federal Employer Identification Number:
Number: (if applicable)
Owner/Corporation Name:
Social Security Number (SSN)/Corporate Identification Number:
Business Name/Doing Business As (DBA):
Business Mailing Address:
City:
State:
ZIP Code:
Business Phone Number:
Business Fax Number:
Business Location (if different from above):
City:
State:
ZIP Code:
II.
REPRESENTATIVE DESIGNATION
(please type or print)
I hereby appoint the following person to represent the employer/taxpayer for specified tax matters arising under
the California Unemployment Insurance Code.
Representative’s Business:
Representative’s Name:
Phone Number:
Fax Number:
Business Mailing Address:
City:
State:
ZIP Code:
III.
AUTHORIZED ACT(S)
GENERAL AUTHORIZATION: If you want to give the representative general authority to perform all acts on your
behalf with regard to your state tax matters.
SPECIFIC DECLARATION:
If you want to give the representative limited authority with regard to your state
From
To
tax matters, indicate the specific dates and acts you are authorizing.
To represent the employer/taxpayer for any and all
☐ Tax Reporting
☐ Benefit Reporting ☐ Both matters relating to the reporting period indicated above.
To represent the employer/taxpayer for changes to their mailing address for any and all
☐ Tax Reporting
☐ Benefit Reporting ☐ Both matters relating to the reporting period indicated above.
Other acts: (describe specifically) _________________________________________________________
Subject to revocation, the above representative is authorized to receive confidential information.
IV. SIGNATURE AUTHORIZING POWER OF ATTORNEY
Signature of the employer/taxpayer, owner, officer, receiver, administrator, or trustee for the
employer/taxpayer: If you are a corporate officer, partner, guardian, tax matters partner/person, executor, receiver,
administrator, or trustee on behalf of the employer/taxpayer, you are certifying that you have the authority to execute
this form on behalf of the employer/taxpayer by signing this Power of Attorney Declaration.
If this Power of Attorney Declaration is not signed and dated, it will be returned as invalid.
I certify under penalty of perjury that the above information is true, correct, and complete, and that these actions are not to be taken to
receive a more favorable Unemployment Insurance rate. I further certify that I have the authority to sign on behalf of the above business.
Signature
Title (Owner, Partner, Corp. Officer: Pres., Vice Pres., CEO or CFO)
Print Name
SSN
Date
DE 48 Rev. 8 (5-17) (INTERNET)
Page 1 of 2
CU
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Parent category: Legal