COM
MONWEALTH OF KENTUCKY
DIVISION OF UNEMPLOYMENT INSURANCE
P.O. BOX 948
FRANKFORT, KY 40602-0948
Power of Attorney for Representing Employer for Unemployment Insurance Related Matters
KentuckyUnbridledSpirit.com An Equal Opportunity Employer M/F/D
Federal Employer Identification Number (FEIN): ________________________
Ken
tucky Employer Identification Number (KEIN): _______________________
Employer: _______________________________________________________________________________
Located at: _____________________________________________________ ______________________
(Street Address, City, State, Zip Code) Telephone
E-mail address: _________________________________________________________________
__________
Hereby authorizes: ________________________________________________________________________
Located at: _____________________________________________________ ______________________
(Street Address, City, State, Zip Code) Telephone
E-mail address: ___________________________________________________________________________
to represent the Employer before the Division of Unemployment Insurance in any and all matters, to act in the
Employer’s stead with the same consequences as the Employer, and to receive any and all information requested
by said Representative pertaining to the Employer’s liability for the payment of contributions, interest and
penalties under the Kentucky Unemployment Compensation Laws and Regulations, until such time as the
appointment is terminated.
This Power of Attorney supersedes and revokes any prior power of attorney authorization from the named
employer relating to the subject matter hereof. The undersigned warrants that he or she is authorized to execute
this Power of Attorney.
________________________________________ _____________
____________________________
Signature Name of Employer
_____________________________________ _________________________________________
Print or Type Name Title
____________________________________
(Please initial one below) Date
____ I respectfully request that my authorized representative be the address of record for all forms and
correspondence pertaining to unemployment tax related matters.
____ The legal mailing address of the named employer shall remain the same. The employer will continue to
receive all correspondence pertaining to unemployment tax related matters.
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties, as agent, may be addressed collectively as ADP New Hampshire.
PO BOX 1390 LONDONDERRY, NH 03053-1390
uidocs@adpunemploymentclaims.com
Initial the first line to have your unemployment
documents sent directly to ADP.
