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Maine Company's Power of Attorney Form

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Maine Company's Power of Attorney Form
Maine Company
Me. UC-28 (rev. 09/2013)
Bureau of Unemployment Compensation
47 State House Station
Augusta ME 04333-0047
That UI Account No.
(Business name)
having its principal office at Federal ID No.
(Business mailing address)
(City) (State) (Zip Code)
hereby constitutes and appoints ___________________________________________________________
(Designated authority)
(Designated authority mailing address)
(City) (State) (Zip Code)
its true and lawful attorney in fact with full power and authority to represent said company before the Maine
Department of Labor, Bureau of Unemployment Compensation, effective immediately and until this authority
has been superseded by another or has been revoked in writing in connection with any and all unemployment
insurance matters as indicated below.
Please check all that apply
1. Filing of completed forms, including claims for refund or account adjustments, assessments, liability
or status determinations, contribution rate and wage record reports.
2. Payment of contributions and any penalties and interest assessed on the account.
3. Obtaining and discussion of all account information required and authorized by the Maine
Employment Security Law.
4. All matters affecting the experience record and contribution rate of the employer account.
5. Employee wage and separation information and employer’s appeal of benefit claims.
Please confirm and provide the mailing address for Items 6 and/or 7 below.
6. Send a copy of all mailings pertaining to unemployment benefits
(C/O Name) (Mailing Address) (City) (State) (Zip Code)
7. Send a copy of all mailings pertaining to unemployment taxes to:
(C/O Name) (Mailing Address) (City) (State) (Zip Code)
IN WITNESS WHEREOF, the said ________________________________________________________
(Signature of 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.
Printed Name of Owner, Officer or Member: Title:
Contact a Representative at (207) 621-5120, select option 3; Fax: (207) 287-3733;
TTY Users Call Maine Relay 711; E-mail address: [email protected]
Avoid missed mailings and potential late fees by notifying MDOL of any
changes to your account.
Maine Company's Power of Attorney Form