Fillable Printable Power of Attorney or Authorization of Agent Form - Utah

Power of Attorney or Authorization of Agent Form - Utah

UTAH DEPARTMENT OF WORKFORCE SERVICES

Unemployment Insurance

P.O. Box 45288

Salt Lake City, Utah 84145-0288

DWS-UI

Form POA

Rev. 10/15

POWER OF ATTORNEY / AUTHORIZATION OF AGENT FORM

KNOW ALL MEN BY THESE PRESENTS:

THAT THE UNDERSIGNED,

( corporation, partnership, individual )

State Identification Number:

Having its principal office at:

Does hereby constitute and appoint:

( legal name and complete address )

its divisions and subsidiaries the true and lawful attorneys-in-fact of the undersigned, until further written notice, to

represent the undersigned before any and all government bodies, agencies or instrumentalities, in all matters

affecting unemployment insurance taxes including, without limitation, the following:

( Check all that is applicable: )

Unemployment tax matters

Each of said attorneys-in-fact shall have the power to act with or without the others and the power authority to

perform, in the name and on behalf of the undersigned, every act necessary to carry out the subject matter hereof

as fully as the undersigned could do. The undersigned hereby ratifies and approves the acts of said

attorneys-in-fact. The services to be performed shall specifically exclude any which now or in the future may be

deemed to be the practice of law.

( MUST check applicable box: )

Please change the address of record to the following attorney-in-fact address:

Unemployment claims matters (determinations, hearing notices, appeals, benefit

charges)

Do not change the address of record.

Federal Identification Number:

State:

This Authorization supersedes and revokes any prior power of attorney

authorization from the undersigned relating to the subject matter hereof, and is

valid from this date until rescinded by a letter or superseded.

IN WITNESS WHEREOF, the undersigned has duly executed and delivered this

Authorization this ___________ day of _______________________, 20___ .

Notary or company seal

Name of Company ( type or print )

Signature ( Authorized Officer)

Name and Title ( type or print )

B y :

WITNESS:

S i g n a t u r e

Name and Title ( type or print )