EMPLOYER POWER OF ATTORNEY ASSIGNMENT
Be Aware That:
,, ,
(Employer Name) (UI Account #) (FEIN #)
having its main office located at ,
(Street Address, City, State & Zip Code)
appoints ,
(Telephone Number with Area Code) (Name of Representing Company)
located at ,,
(Street Address, City, State & Zip Code) (Telephone Number with Area Code)
as its attorney or representative with full power to represent the employer before the Wisconsin Unemployment Insurance
Division. This representation applies to all matters affecting unemployment insurance including, although not limited to,
all benefit claims, contributions, refunds, experience rating, hearings and appeals.
The employer further understands the Wisconsin Unemployment Insurance Division maintains three (3) separate and
distinct mailing groups* which include:
Group I UCB-16 Separation Notice
UCB-23 Wage Verification/Eligibility Report
UCB-20 Determination
Group II UCT-14384-1-E Unemployment Insurance Benefit Charges and Adjustments
Group III UCB-719 Urgent Request for Wages
UCB-701 Computation of Unemployment Insurance Benefits
UCB-708 Notice of Changed Liability for UI Benefits
UCT-101-E Quarterly Contribution Report
UCT-14384-E Unemployment Insurance Reserve Fund Balance Statement
UC-7823-E Quarterly Wage Reports
UCT-14309-E Reimbursable Employer Monthly Statement
* Forms listed above must remain within the respective mailing group
The employer authorizes group(s) to be mailed to the representative's address listed above.
(List Group Number(s))
The remaining group(s) will be mailed to the employer's main office.
(List Group Number(s))
By the signatures below, the employer known as ,
(Employer Name)
approves the above directions and voluntarily enters into this assignment on ,
(Date – mm/dd/yyyy)
at which time this assignment is effective and takes place of all previous assignments.
Authorized Signature:
(Employer Signature) (Date Signed – mm/dd/yyyy)
Printed Name & Title:
(Print Name) (Job Title)
Witnessed By:
(Witness Signature) (Date Signed – mm/dd/yyyy)
Printed Name & Title:
(Print Name) (Job Title)
UCT-8291-E (R. 02/2018)
Department of Workforce Development
Unemployment Insurance
Fax: (608) 327-
I, II
III
PO BOX 1390 LONDONDERRY NH 03053-1390
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties may be addressed collectively as ADP NEW HAMPSHIRE.
