Fillable Printable Limited Power of Attorney Template - Maine
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.
