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Georgia Limited Power of Attorney Form

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Georgia Limited Power of Attorney Form
THAT, ________________________________, GA DOL Account No. _________________,
having its principal office at ______________________________________________________
hereby appoints ______________________________ as its true and lawful agent with authority
to represent the said _______________________ before the Georgia Department of Labor,
until further notice, in connection with all matters affecting State Unemployment Insurance
Taxes including, with limitation, tax contributions and experience ratings, but excluding claims.
This Power of Attorney supersedes and revokes any prior power of attorney authorization from
the named employer relating to the subject matter hereof. The undersigned warrants that he or
she is authorized to execute this Power of Attorney.
The legal mailing address of the named employer shall remain the same. The employer will
continue to receive all correspondence pertaining to contributions, claims and experience
IN WITNESS WHEREOF, the undersigned has duly executed and delivered this Power of
Attorney on behalf of the named employer this _______ day of ___________________, 20___.
Employer’s Name
By: ___________________________________
Print or Type Name
Georgia Limited Power of Attorney Form