UTAH DEPARTMENT OF WORKFORCE SERVICES
Unemployment Insurance
P.O. Box 45288
Salt Lake City, Utah 84145-0288
DWS-UI
Form POA
Rev. 09/16
POWER OF ATTORNEY / AUTHORIZATION OF AGENT FORM
KNOW ALL MEN BY THESE PRESENTS:
THAT THE UNDERSIGNED,
a
( corporation, partnership, individual )
State Identification Number:
Having its principal office at:
Does hereby constitute and appoint:
its divisions and subsidiaries the true and lawful attorneys-in-fact of the undersigned, until further written notice, to
represent the undersigned before any and all government bodies, agencies or instrumentalities, in all matters
affecting unemployment insurance taxes including, without limitation, the following:
( Check and complete all applicable types )
Unemployment tax matters
Each of said attorneys-in-fact shall have the power to act with or without the others and the power authority to
perform, in the name and on behalf of the undersigned, every act necessary to carry out the subject matter hereof
as fully as the undersigned could do. The undersigned hereby ratifies and approves the acts of said
attorneys-in-fact. The services to be performed shall specifically exclude any which now or in the future may be
deemed to be the practice of law.
Unemployment claims matters (determinations, hearing notices, appeals, benefit
charges)
Federal Identification Number:
State:
Fax (801) 526-9377
( Agent legal name )
Agent City, State and Zip
Agent Telephone
Agent Address
Agent City, State and Zip
Agent Telephone
Agent Address
Check this box to send new correspondence to the above address.
Check this box to send new correspondence to the above address.
ADP. LLC and its subsidiaries and Corporate Cost Control, LLC
The parties may be addressed as ADP New Hampshire.
ADP-CCC UNEMPLOYMENT CLAIMS
