Fillable Power of Attorney for Unemployment Insurance (ADP)

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Power of Attorney for Unemployment Insurance (ADP)

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The Power of Attorney for Unemployment Insurance (ADP) form is 2 pages long and contains:

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  • 1 check-box
  • 43 other fields

Country of origin: US
File type: PDF

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ID 1200 ( revised) Power of Attorney form
Power of Attorney for Unemployment Insurance
This authorization allows the Employment Security Department to send or share confidential information about
your unemployment insurance account with your designated representative. Please complete all information below.
It must match the records we have on file for your business. *Employers must have an actual ESD account
number issued and listed on this form in order to submit for processing.
Section 1 – Employer information
Business name: ESD number*:
Business phone number: EIN:
Mailing address line 1: UBI number:
Mailing address line 2:
City: State: Zip code:
Employer contact name and title:
Contact phone number:
Contact email:
Section 2 – Representative for Tax purposes
Representative EIN (required):
Representative organization name:
Mailing address line 1:
Mailing address line 2:
City: State: Zip code:
Representative contact name:
Contact phone number:
Contact fax number:
Contact email:
Section 3 – Confidential tax information
Authorizations: Please select the boxes that indicate how much authority you’d like to give your representative.
Unemployment insurance tax reports and amendments
Tax payments and billing statements
Electronic access to information as available
Audit of unemployment insurance taxes
Enter into agreements
Represent and make oral or written presentations of fact and/or argument
Mailing tax documents:
Please select the address ESD should use when mailing tax documents. (mark ONLY ONE)
Employer’s mailing address. (
Use the Business Change Form to report any change of business address.)
Representative’s address in section 2 above
Mailing billings:
Please select the address ESD should use when mailing billings and payment notices. (mark ONLY ONE)
Employer’s mailing address.
(Use the Business Change Form to report any change of business address.)
Representative’s address in section 2 above
Clear Form
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46-5358523
ADP and Corporate Cost Control
c/o ADP UNEMPLOYMENT CLAIMS
MISSOULA
PO BOX 17617
MT
855-537-8499
855-537-8536
uidocs@adpunemploymentclaims.com
ID 1200 ( revised) Power of Attorney form
Section 4 – Representative for Benefits purposes Same as above. (Skip this section if checked.)
Representative EIN (required):
Representative organization name:
Mailing address line 1:
Mailing address line 2:
City: State: Zip code:
Representative contact name:
Contact phone number:
Contact fax number:
Contact email:
Section 5 – Confidential benefits information
Authorizations: Please select the boxes that indicate how much authority you’d like to give your representative.
Benefits charges
Benefit claims
Electronic access to information as available
Enter into agreements
Represent and make oral or written presentations of fact and/or argument
Mailing benefit GRFXPHQWV:
Please select the address ESD should use when mailing benefit documents. (mark ONLY ONE)
Employer’s mailing address on record.
(Use the Business Change Form to report any change of business address.)
Representative’s mailing address in Section 2 on the first page
Representative’s mailing address in Section 4 above
Effective Date:
Your authorizations selected will remain in effect as of the beginning authorization date until you revoke them in
writing.
Beginning authorization date:
I, the undersigned, declare under the penalties of perjury that I am the business owner or officer
duly authorized to represent this account and further declare that the information submitted has
been examined by me and that the matters and statements set forth are true, correct and complete.
Governing person signature: Date:
Name of signee: Title:
If you have questions, please contact the Registration Unit at .
Please sign this form and fax to 800-794-7657, email to uifiles@esd.wa.gov,ormailto:
Employment Security Department, Registration Unit, P.O. Box 9046, Olympia, WA 98507-9046
46-5358523
ADP and Corporate Cost Control
c/o ADP UNEMPLOYMENT CLAIMS
PO BOX 17617
MISSOULA
MT
855-537-8499
855-537-8536
uidocs@adpunemploymentclaims.com
SIDES: BR000000022
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Power of Attorney for Unemployment Insurance (ADP)

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Completed 8 February 2021

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