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

State Purge Letter To Employer/Fpd (De974A)

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

COUNSELING SERVICE AGENT REGISTRATION FORM

Please complete and return this Counseling Service Agent Registration Form, DE 974A, with the list of

your current clients to represent them in benefit or benefit and tax matters with 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 Service Agent 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)?

Yes No

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

Statement of Charges to Reserve Account, DE 428T, electronically?

Yes No

Mail this completed registration form, client listing, and Power of Attorneys to:

Attention: Agent Desk

Employment Development Department

Account Services Group, MIC 13

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.: