Fillable Printable State Purge Letter To Employer/Fpd (De974A)

State Purge Letter To Employer/Fpd (De974A)

DE 974ARev. 2 (3-17) (INTERNET)Page 1 of 1CU

COUNSELING SERVICE AGENT REGISTRATION FORM

Please complete and return this Counseling Service Agent Registration Form,DE974A, with thelist of

your current clients to represent themin benefitor benefit and tax matterswith the Employment

Development Department (EDD).Note: Your registration request cannot be processed without

this information.

1. Counseling Service Agent Company Information:

Business Name:

Address:

2. Counseling ServiceAgent Contact Information:

Representative Name(Primary):

Phone Number:

Fax Number:

Representative Name (Secondary):

Phone Number:

Fax Number:

3.Total number of clients to date:

4.Would you like information about Electronic Data Interchange (EDI)?

YesNo

5.Would you like information about the EDD’s e-Services for Business to receive the

Statementof Charges to Reserve Account,DE428T, electronically?

YesNo

Mail thiscompleted registration form, client listing, and Power of Attorneysto:

Attention: AgentDesk

Employment Development Department

Account Services Group, MIC13

PO Box 826880

Sacramento, CA 94280-0001

Fax: 916-654-9211

For additional information, contact the Agent Desk at 916-654-7263

INTERNAL USE ONLY: CS AGENT CODE NO.: