"Third Party Authorization Form" - Montana

Third Party Authorization Form is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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••
Montana Department of
@ ..
•. • •
LABOR
& INDUSTRY
Unemployment Insurance Division
Contributions Bureau
PO Box 6339, Helena, MT 59604-6339
Telephone (406) 444-3834
Third Party Authorization Form
Employer
Montana UI Employer Account Number
Federal ID Number
Owner/Officer/Partner Name
Doing Business As
Mailing Address (Street or PO Box)
City, State Zip Code
Telephone Number
Email Address
Third Party Agent (TPA)
Authorized Third Party Agent
Federal ID Number
Begin Authority As Of (date)
UI eServices Web Logon(s) (if known)
Mailing Address (Street or PO Box)
City, State Zip Code
Telephone Number
Email Address
CONSENT & AUTHORIZATIONS
Please check or initial all applicable authorizations for the above listed TPA.
Verbal Communications: I hereby certify the Montana Department of Labor & Industry Unemployment Insurance
Division is authorized to speak with the above third-party agent concerning all matters related to my unemployment insurance
account.
UI eServices for Employers Access: I hereby certify the Montana Department of Labor & Industry Unemployment
Insurance Division is authorized to grant the above TPA the following level of access to my UI account via UI eServices for
Employers, (please see page 3 for detailed descriptions of the access levels –check only one):
File Only Access
SIDES e-Response Access
Pay Only Access
Full Access
File & Pay Access
Written Communications: I hereby certify the Montana Department of Labor & Industry Unemployment Insurance
Division is authorized to direct UI related correspondence to the above third-party agent. I authorize the following mailings to
be sent directly to the above TPA (check all that apply):
Miscellaneous forms and notices including but not limited to: UI5 Quarterly Wage Reports, monthly Statements
of Account, delinquent notices, registration related forms, and credit memos. Excludes Rate Notices.
UI Tax Rate Notices
Quarterly or monthly benefit charge notices
Benefit Claim related correspondence including Separation and Potential Charge notices
1
:
••
Montana Department of
@ ..
•. • •
LABOR
& INDUSTRY
Unemployment Insurance Division
Contributions Bureau
PO Box 6339, Helena, MT 59604-6339
Telephone (406) 444-3834
Third Party Authorization Form
Employer
Montana UI Employer Account Number
Federal ID Number
Owner/Officer/Partner Name
Doing Business As
Mailing Address (Street or PO Box)
City, State Zip Code
Telephone Number
Email Address
Third Party Agent (TPA)
Authorized Third Party Agent
Federal ID Number
Begin Authority As Of (date)
UI eServices Web Logon(s) (if known)
Mailing Address (Street or PO Box)
City, State Zip Code
Telephone Number
Email Address
CONSENT & AUTHORIZATIONS
Please check or initial all applicable authorizations for the above listed TPA.
Verbal Communications: I hereby certify the Montana Department of Labor & Industry Unemployment Insurance
Division is authorized to speak with the above third-party agent concerning all matters related to my unemployment insurance
account.
UI eServices for Employers Access: I hereby certify the Montana Department of Labor & Industry Unemployment
Insurance Division is authorized to grant the above TPA the following level of access to my UI account via UI eServices for
Employers, (please see page 3 for detailed descriptions of the access levels –check only one):
File Only Access
SIDES e-Response Access
Pay Only Access
Full Access
File & Pay Access
Written Communications: I hereby certify the Montana Department of Labor & Industry Unemployment Insurance
Division is authorized to direct UI related correspondence to the above third-party agent. I authorize the following mailings to
be sent directly to the above TPA (check all that apply):
Miscellaneous forms and notices including but not limited to: UI5 Quarterly Wage Reports, monthly Statements
of Account, delinquent notices, registration related forms, and credit memos. Excludes Rate Notices.
UI Tax Rate Notices
Quarterly or monthly benefit charge notices
Benefit Claim related correspondence including Separation and Potential Charge notices
1
I
I
State Information Data Exchange System (SIDES) e-Response Participation:
(see page 3 for more information on SIDES)
If the TPA listed on page one will NOT be responding to benefit claim information requests on your behalf via SIDES e-
Response, this section should remain blank. If a separate TPA will be responding to benefit claim requests on your behalf, you
will need to complete an additional authorization form for them. If you will be responding to your own benefit claim requests and
would like to use SIDES, logon to eServices and complete your contact information online (no form is needed).
Complete the SIDES contact information below, only if the TPA listed on page one WILL be responding to benefit claim related
requests on your behalf via SIDES.
NOTE: Access to eServices is required for a TPA to respond to SIDES requests on your behalf. Please be sure to
indicate either SIDES e-Response or Full Access on page one under UI eServices for Employers Access.
The SIDES contact(s) listed below will receive email notifications if/when there are requests for Benefit Claim related
information (Separation Inquiries, Potential Charge Notices, etc.). You have the option to designate one contact to receive all
notifications OR list a separate contact for each request type.
SIDES Contact(s)
SIDES Separation Request Contact Name
Contact Email Address
Contact Telephone Number
SIDES Charging Request Contact Name
Contact Email Address
Contact Telephone Number
SIDES Employment Verification Request Contact Name
Contact Email Address
Contact Telephone Number
SIDES Decisions & Determinations Request Contact Name
Contact Email Address
Contact Telephone Number
Signature of the Employer/Taxpayer
I relieve the Department and their representatives of any liability related to release of such information to the above-named
authorized third-party agent. I understand this authorization does not absolve me, as the employer/taxpayer, of the
responsibility to ensure all taxes, tax reports and/or other UI notices are filed and/or paid timely and accurately. Any
authorization granted remains in effect until revoked in writing by the taxpayer or the third-party agent.
The person completing this section and signing below must have legal authority to bind the business. Persons may
include the owner, corporate officer, partner, managing member, Chief Financial Officer, Chief Executive Officer, or a fiduciary
of a trust or estate.
I certify I have the legal authority to execute this form and
authorize disclosure of information noted above:
PRINTED NAME & TITLE of Authorized Person
PRINTED NAME of Witness to Authorized Person (Required)
SIGNATURE of Authorized Person
DATE
SIGNATURE of Witness (Required)
DATE
2
Instructions for Completing Authorization Form:
Ensure both the Employer and Third-Party Agent (TPA) sections are completed. Note: If you have multiple third-
party agents performing UI related services for you, you will need to complete a separate authorization form for
each of them.
Check or initial all appropriate authorizations (verbal, written, eServices, and/or SIDES). Don’t forget to indicate
the mail types and/or the eServices access level you are authorizing.
IF the TPA listed on page one will be responding to unemployment benefit claim requests for information, on your
behalf, via SIDES, complete the SIDES e-Response Participation section.
An owner, officer, or other person authorized to bind the business must print and sign their name in the Signature
Section.
A witness must also sign and date the form.
Return the form to UI Contributions electronically or by mail:
Email:
uieservices@mt.gov
Upload into eServices:
https://uieservices.mt.gov
Fax: (406) 444-0629
Mail: PO Box 6339 Helena MT 59604-6339
eServices Access Level Descriptions:
File Only Access – Allows the user to file quarterly UI tax reports. Includes limited viewing of UI tax information such as:
filed quarterly reports, rate history information, and general activity history and the ability to send and receive secure
messages to/from Montana UI Staff.
Pay Only Access – Allows the user to make payments on UI tax, penalty, or interest. Includes limited viewing of UI tax
information such as: viewing filed quarterly reports, rate history information, and general activity history and the ability to
send and receive secure messages to/from Montana UI Staff.
File & Pay Access – Allows the user to both file quarterly UI tax reports and make payment. Includes limited viewing of
UI tax information such as: viewing filed quarterly reports, rate history information, and general activity history. Also
includes the ability to send and receive secure messages to/from Montana UI Staff and the ability to upload bulk reporting
files or submit fiscal rate exchange files.
SIDES e-Response Access– Includes the ability to access the State Information Data Exchange System (SIDES) to
respond to benefit claim requests. Includes limited viewing of UI tax information such as: viewing filed quarterly reports,
rate history information, and general activity history and the ability to send and receive secure messages to/from Montana
UI Staff. NOTE: The SIDES e-Response Participation section of the authorization form must be complete for this access
level to be granted.
Full Access - Expanded viewing of UI tax related information, including benefit charge information and correspondence
sent. Ability to file quarterly reports, make payments, update demographic information, send/receive messages, and
submit requests for refunds and/or waivers of penalty and interest. Also includes the ability to access the State
Information Data Exchange System (SIDES) to respond to benefit claim requests.
SIDES
What is the State Information Data Exchange System (SIDES)? It’s a convenient and secure way to electronically
respond to requests for information in regard to unemployment insurance benefit claims. Developed by the U.S.
Department of Labor and the National Association of State Workforce Agencies (NASWA), SIDES e-Response provides a
nationally standardized format for responding to UI information requests.
UI eServices for Employers acts as a doorway into the SIDES e-Response portal. By participating in SIDES e-Response
through eServices, a designated SIDES contact will receive email notifications anytime there is a request waiting. The
contact can then log into eServices, see and respond to any requests waiting.
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