Fillable LIMITED POWER OF ATTORNEY

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LIMITED POWER OF ATTORNEY

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UIT-1146A FORFF (4-18)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Employer Engagement Administration
P.O. BOX 6028, Mail Drop 5881, Phoenix, AZ 85005-6028
LIMITED POWER OF ATTORNEY
EMPLOYER INFORMATION
EMPLOYER NAME ARIZONA UI ACCOUNT NO. OR FEDERAL EIN
Hereby appoints
(Representative Company’s Name) (Representative Company’s Phone No.)
To represent said employer before the Arizona Department of Economic Security (DES) in all matters related to Arizona
Unemployment Insurance (UI) specied below until further notice (check all boxes that apply):
UI tax preparation/ling including ling/paying via the Internet Tax and Wage System (TWS)
All other general UI matters (all benet claim protests, all appeals of agency determinations, etc.)
Other, specic UI matter (provide details below to identify the matter or no action will be taken):
Provide representative’s address if you want mail concerning the “Other, specic UI matter” sent there:
REPRESENTATIVES COMPANY’S ADDRESS (P.O. Box/Street No., Street, City, State, ZIP)
COMPLETE THIS AREA ONLY IF YOU WANT TO CHANGE THE EMPLOYER’S PRIMARY MAILING ADDRESS
EMPLOYER NAME
PHONE NO.
ADDRESS (P.O./Street No. Street, City, State, ZIP)
*All general UI correspondence including liability determinations, tax and wage report forms, tax assessments, and notices of tax rates,
benet charges, appeals, liens and claim lings are mailed to the PRIMARY address. If you want a SEPARATE mailing address for
notices of unemployment benet claim lings, claim determinations and claim appeals, complete the address area below.
OPTIONAL SEPARATE MAILING ADDRESS FOR UNEMPLOYMENT BENEFIT CLAIM-RELATED NOTICES
EMPLOYER NAME
PHONE NO.
ADDRESS (P.O./Street No. Street, City, State, ZIP)
In witness whereof, said employer has caused this instrument to be attested by the signature of a duly qualied ofcer or owner this day of
(Day) (Month) (Year) .
This Limited Power of Attorney authorization cancels and/or supersedes all prior authorizations related to the specied matters and
remains in effect until revoked in writing by either the employer or the representative
PRINT NAME (First, M.I, Last) TITLE
SIGNATURE
FOR AGENCY USE ONLY
REVISED PRIMARY ADDRESS REVISED/ADDED
CLAIMS ADDRESS
INITIALS DATE NOTES
Public Partnerships, LLC
(844) 225-3659
Owner
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LIMITED POWER OF ATTORNEY

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Completed 23 June 2021

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