Fillable I. Business/Taxpayer (ADP)

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I. Business/Taxpayer (ADP)

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The I. Business/Taxpayer (ADP) form is 1 page long and contains:

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  • 5 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
POWER OF ATTORNEY
I. Business/Taxpayer
Name
Address
City
State
Zip Code
Phone Number
FEIN
II. Does Hereby Appoint
Name of Appointed Representative
Phone Number
Address
City
State
Zip Code
as attorney(s)-in-fact to represent taxpayer before the Missouri Division of Employment Security with respect to the
following Unemployment Insurance matter(s):
Type of Representation (check one)
U I Tax and Claim Matters U I Tax Only U I Claim Only
Change employer’s official mailing address to that of appointed representative for: (check all that apply)
U I Tax Matters U I Claim Matters
This authorization supersedes and revokes any prior power of attorney or authorization on file with the
Missouri Division of Employment Security relating to the subject matter hereof.
The authorization does not apply to the Division of Employment Security appeals process.
III. Signature of Business Representative/Taxpayer
Name (printed)
Title
Signature
Date
IV. Signature of Appointed Representative
Name (printed)
Title
Signature
Date
V. Please send completed form to:
Missouri Division of Employment Security
Attn: Liability Unit
P O Box 59
Jefferson City, MO 65104-0059
MODES-4444 (08-11) AI
Cont.
ADP, LLC, and its subsidiaries and Corporate Cost Control, LLC.
The parties may be addressed collectively as ADP NH.
855-537-8499
PO BOX 1390
LONDONDERRY
NH
03053-1390
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I. BusinessTaxpayer (ADP)

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Completed 8 February 2021

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