Fillable Form 182059: EMPLOYER'S REPRESENTATIVE AUTHORIZATION Section I - (ADP)

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Form 182059: EMPLOYER'S REPRESENTATIVE AUTHORIZATION Section I - (ADP)

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The Form 182059: EMPLOYER'S REPRESENTATIVE AUTHORIZATION Section I - (ADP) form is 2 pages long and contains:

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  • 14 check-boxes
  • 38 other fields

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JFS 00501 (Rev. 10/2010) Page 1 of 2
Ohio Department of Job and Family Services
EMPLOYER'S REPRESENTATIVE AUTHORIZATION
P.O. BOX
182059
Columbus, OH 43215-2059
(614) 466-4047
EMPCHRG@jfs.ohio.gov
Section I - Benefits Authorization for Representation or Dissolution of Representation
I hereby authorize the Ohio Department of Job and Family
Services to allow the representative named in Section II to act
on my behalf for all matters pertaining to the service functions(s)
identified in Section III.
NOTE: If correspondence should be sent on a regular basis to
the representative, please choose representative for question
#1.b in Section III.
I am hereby notifying the Ohio Department of Job and Family
Services that I wish to dissolve my relationship with the
representative named in Section II. The Ohio Department of Job
and Family Services should no longer allow the representative
named in Section II to act on my behalf for matters pertaining to the
service function(s) identified in Section III or send them any
information pertaining to my account.
Section II - Employer and Representative Information
When completing this form, please print using block capital letters in black ink. For example:
Employer Name
Employer Address
City
State Zip Country
-
Employer Account Number FEIN
- -
Employer Phone Number
-
-
Representative or Third Party Administrator Name
Representative or Third Party Administrator Number Representative or Third Party Administrator Phone Number
-
-
Representative Address Line 1
Representative Address Line 2 - Please enter P.O. Box here
City
State Zip Country
-
Province - International addresses only Postal Delivery Code - International addresses only
A
B
C
D E F
G
H
I
Clear Form
PRINT
SAVE
ALL TEXT MUST BE UPPER CASE ONLY
A D P & C O R P O R A T E C O S T C O N T R O L
6 0 0 0 0 0 8 6 9 5
8 5 5
5 3 7
A D P U N E M P L O Y M E N T C L A I M S
P O B O X 1 3 9 0
L O N D O N D E R R Y
N H
0 3 0 5 3
1 3 9 0
U S A
JFS 00501 (Rev. 10/2010) Page 2 of 2
Section III - Service Function and Correspondence
1.a To what service function(s) does the authorization or 1.b For the service function(s) selected in question #1 a, where
dissolution selected in Section II apply? should the correspondence be sent on a regular basis?
(Please check all that apply) (Choose only one)
Monthly Benefit Charge Statement Employer Representative or Third Party Administrator
Request for Information Employer Representative or Third Party Administrator
Request for Separation Information Interface Employer Representative or Third Party Administrator
Determinations Employer Representative or Third Party Administrator
Appeals Employer Representative or Third Party Administrator
Employer Third Party Administrator Employer Representative or Third Party Administrator
Section IV - Signature
I hereby acknowledge that by signing this document I relieve the Ohio Department of Job and Family Services from any liability arising from the exercise
of rights and causes of action on account of or growing out of failure of the undersigned to receive any correspondence sent to the representative as
indicated in Section III, including but not limited to:
1. Notification required by Section 4141.26
2. Injury cased by untimely appeal
This authorization, voluntarily given by the undersigned, shall remain in full force and effect until such time as the agency is notified in writing by the
undersigned or by the designated representative that the relationship has been dissolved.
Employer Signature
NOTE: Must be owner, partner, member or corporate officer Title
Date
/
/
Employer Name
Employer Phone Number
-
-
ALL TEXT MUST BE UPPER CASE ONLY
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Form 182059: EMPLOYER'S REPRESENTATIVE AUTHORIZATION Section I - (ADP)

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Completed 8 February 2021

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