"Power of Attorney and Declaration of Representative" - North Carolina

Power of Attorney and Declaration of Representative is a legal document that was released by the North Carolina Department of Commerce - a government authority operating within North Carolina.

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NC Dept. of Commerce
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Division of Employment Security
Post Office Box 26504, Raleigh, NC 27611-6504
(* All fields are required unless specified optional *)
POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE
Part 1. Employer’s Information. Must sign and date this form on page 2
STATE UNEMPLOYMENT TAX ACCOUNT NUMBER
EMPLOYER'S NAME AND ADDRESS
(Exactly as shown on the Division of Employment Security Records)
-
-
FEDERAL EMPLOYER IDENTIFICATION NUMBER
-
Part 2. Representative
PHONE NUMBER
REPRESENTATIVE NAME
CITY, STATE, ZIPCODE
ADDRESS
EMAIL ADDRESS
FAX NUMBER
The above representative is appointed to represent the above-referenced employer in any of the matters pertaining
to contributions (tax) and benefits (claims) as listed below. An agent appointed pursuant to this Power of Attorney
and Declaration may:
1. Complete and submit documents for filing employer’s tax and wage reports;
2. Complete and submit documents regarding an employer’s tax rate, contributions, and direct reimbursements;
3. Respond to benefit claims documents, including responding to requests for information about a
claimant’s separation or status;
4. Engage in discussion with a representative of the Division of Employment Security regarding the actions listed
above;and
5. Accept or receive correspondence sent by DES regarding claims for benefits or an employer’s contributions.
The undersigned employer acknowledges that the agent appointed pursuant to this Power of Attorney
and Declaration of Representative is not authorized to: (a) Represent the employer in hearings (b)
Enter appeals except as authorized by N.C. Gen. Stat. § 96-17(b), and 04 N.C. Admin. Code
24A.0110(a) and (b).
The undersigned employer further acknowledges that its mailing address for tax matters will remain
unchanged, unless the employer submits a change of address in accordance with 04 N.C. Admin.
Code 24A.0102.
Part 3. Remitter Number
Your representative may request a Tax or a Claims remitter number with this Division to perform above services on behalf of your
business. If your representative has a remitter number, please provide this number below. If not, visit the Division’s website at
www.des.nc.gov/employers
and click on ‘Third-Party Administrators and Remitters’ for more information.
TAX remitter number:
(optional)
CLAIMS remitter number:
(optional)
Page 1 of 2
NC Dept. of Commerce
PRINT
CLEAR
Division of Employment Security
Post Office Box 26504, Raleigh, NC 27611-6504
(* All fields are required unless specified optional *)
POWER OF ATTORNEY AND DECLARATION OF REPRESENTATIVE
Part 1. Employer’s Information. Must sign and date this form on page 2
STATE UNEMPLOYMENT TAX ACCOUNT NUMBER
EMPLOYER'S NAME AND ADDRESS
(Exactly as shown on the Division of Employment Security Records)
-
-
FEDERAL EMPLOYER IDENTIFICATION NUMBER
-
Part 2. Representative
PHONE NUMBER
REPRESENTATIVE NAME
CITY, STATE, ZIPCODE
ADDRESS
EMAIL ADDRESS
FAX NUMBER
The above representative is appointed to represent the above-referenced employer in any of the matters pertaining
to contributions (tax) and benefits (claims) as listed below. An agent appointed pursuant to this Power of Attorney
and Declaration may:
1. Complete and submit documents for filing employer’s tax and wage reports;
2. Complete and submit documents regarding an employer’s tax rate, contributions, and direct reimbursements;
3. Respond to benefit claims documents, including responding to requests for information about a
claimant’s separation or status;
4. Engage in discussion with a representative of the Division of Employment Security regarding the actions listed
above;and
5. Accept or receive correspondence sent by DES regarding claims for benefits or an employer’s contributions.
The undersigned employer acknowledges that the agent appointed pursuant to this Power of Attorney
and Declaration of Representative is not authorized to: (a) Represent the employer in hearings (b)
Enter appeals except as authorized by N.C. Gen. Stat. § 96-17(b), and 04 N.C. Admin. Code
24A.0110(a) and (b).
The undersigned employer further acknowledges that its mailing address for tax matters will remain
unchanged, unless the employer submits a change of address in accordance with 04 N.C. Admin.
Code 24A.0102.
Part 3. Remitter Number
Your representative may request a Tax or a Claims remitter number with this Division to perform above services on behalf of your
business. If your representative has a remitter number, please provide this number below. If not, visit the Division’s website at
www.des.nc.gov/employers
and click on ‘Third-Party Administrators and Remitters’ for more information.
TAX remitter number:
(optional)
CLAIMS remitter number:
(optional)
Page 1 of 2
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Part 4. Declaration of Representative
This Power of Attorney and Declaration of Representative shall become effective on
and shall remain in effect until revoked by the employer, the representative, or the Division of
Employment Security. On the effective date, this Power of Attorney and Declaration of Representative
revokes any earlier power of attorney on file with the Division of Employment Security.
(SEAL)
AUTHORIZING SIGNATURE
(Individual signing must be the proprietor, a general partner or duly elected corporate official exactly as shown on the Division of
Employment Security records).
TITLE
TYPED OR PRINTED NAME
SIGNED AND SWORN to before me on this
day of
.
E-NOTARY PUBLIC SEAL
REPRESENTATIVE SIGNATURE
TYPED OR PRINTED NAME
TITLE
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