Department of Labor, Licensing and Regulation
Division of Unemployment Insurance
Power of Attorney Authorization Form
E
mployer/Taxpayer
1. M
aryland Unemployment Insurance Account Number: ______________________________
2. Federal Employer Identification Number: _________________________________________
3. Name of Employer/Taxpayer: __________________________________________________
4. Address: ___________________________________________________________________
___________________________________________________________________________
Reporting Agent
1. N
ame of Reporting Agent:____________________________________________________
2. Address: ___________________________________________________________________
___________________________________________________________________________
3. Telephone Number: __________________________________________________________
Authorization
C
heck the authorization that is granted to the Reporting Agent. (Check all that apply.)
1. [ ] File, sign and date the quarterly unemployment insurance contribution/employment
report
2. [
] Make payments on behalf of the employer/taxpayer
3. [ ] Receive and respond to confidential information regarding quarterly contributions and
t
ax rates.
4. [
] Receive and respond to confidential information regarding unemployment insurance
claims filed by employees of the employer/taxpayer
E
ffective Date of Authorization
____
__________________________
Name and Signature of Employer/Taxpayer
_________________________
Name
____
___________________ ___________________________ ____________
Signature Title Date
Submit to: Maryland Unemployment Insurance Refer Questions to: 410-767-3223
Employer Status Unit FAX: 410-767-2848
1110 N. Eutaw St., Room 409 Email: status@dllr.state.md.us
Baltimore, Maryland 21201
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties may be addressed collectively as ADP NH.
LONDONDERRY NH 03053-1390
