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Alaska Company's Power of Attorney Form


Alaska Company's Power of Attorney Form
Alaska Company
ALASKA DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Employment Security Division Unemployment Insurance (UI) Tax
1111 W. 8
th
Street, P.O. Box 115509, Juneau, AK 99811-5509
1-888-448-3527 or (907) 465-2757, Fax: (907) 465-2374;
TTY/TDD: 1-800-770-8973 or E-mail address: esd_tax@labor.state.ak.us
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
That________________________________________________ UI Account No. _______________
(business name)
Federal ID No. ________________having its principal office at __________________________________________
(business mailing address)
____________________________________
City State Zip Code
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, Employment Security Division effective immediately and until
this authority has been revoked in writing in connection with any and all unemployment insurance matters as
indicated below:
[ ]
1. Filing of completed forms, including claims for refund or adjustment of account, liability or status
determinations and wage record reports.
[ ] 2. Receipt of blank Quarterly Contribution Report Form (TQ01)
[ ] 3. Receipt of Tax Rate Notices (TR02)
[ ] 4. Payment of contributions and any penalties and interest assessed on the account.
[ ] 5. Discuss matters affecting the experience record and contribution rate of the employer account.
[ ] 6. Discuss all matters affecting any adjustments to the employer’s account.
[ ] 7. All matters and forms affecting UI benefits, job separation information, hearing notices and decisions.
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____. This authorization cancels and supersedes all prior authorizations for
authority indicated in areas 1 through 7 above.
Company Name:
By
( employer signature):
Title:
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.
Notary Public
Type or Print Name
My Commission Expires
rev 05/12)
Alaska Company's Power of Attorney Form