Fillable Printable Limited Power of Attorney Template - Maine

Limited Power of Attorney Template - Maine

LIMITED POWER OF ATTORNEY FORM

Name of AIF (print): _________________________________________________

Address of AIF: _________________________________________________

Ph. Number : _________________________________________________

Tax Type: _________________________ Tax Period:______________

Name of Taxpayer (print):___________________________________________________

Date of Birth: __________________________

Social Security Number/Tax ID Number : _____________________________________

Address of Taxpayer : _________________________________________________

Ph. Number : _________________________________________________

______________________________________________ _________________________

Taxpayer Signature, Title Date

NOTICE: This form does NOT revoke other power of attorney forms on ﬁ le with MRS.

Please read, ﬁ ll out, and sign this form if you wish to appoint an attorney-in-fact (“AIF”). Your

tax record information kept by MRS is conﬁ dential by law. This includes all returns and ﬁ lings

made by you. This form allows MRS to discuss your tax record information with your AIF. Your

tax records are all your tax information on ﬁ le with MRS.

I understand that my tax records are conﬁ dential under State law.

I authorize my named AIF to discuss information in my tax records with MRS.

I authorize MRS to discuss information in my tax records with my named AIF.

Revised 06/11

STATE OF MAINE

MAINE REVENUE SERVICES

24 STATE HOUSE STATION

AUGUSTA, MAINE 04333-0024

Withholding

N/A

Me. UC-28 (rev. 07/2011)

MAINE DEPARTMENT OF LABOR

Bureau of Unemployment Compensation

47 State House Station

Augusta ME 04333-0047

POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That UI Account No.

(Business name)

having its principal office at Federal ID No.

(Business mailing address)

Telephone

(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 revo ked in writing in connection with any and all unempl oyment

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 infor m ation 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

to:

______________________________________________________________________________

(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 su persedes a ll prior author izations.

Printed Name of Owner, Officer or Member: Title:

QUESTIONS ABOUT THIS NOTICE?

Contact a Representative at (207) 621 -5120, select option 3; Fax: (207) 2 87-3733;

TTY (Deaf / Hard of Hearing): 1-800-794-1110; E-m ail address: [email protected]

Avoid missed mailings and potential late fees by notifying MDOL of any

changes to your account.