Rev. 8/17
ALASKA DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Employment and Training Services – Unemployment Insurance (UI) Tax
1111 W. 8
th
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immediately and until this authority has been revoked in writing in connection with any and all Unemployment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____.
(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.
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC., known as ADP NH.
NOTARY REQUIRED
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Original Signature Required
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